THE  LIBRARY 
OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


THE  STUDENT'S  GUIDE 


DISEASES  OF  THE  EYE. 


STUDENT'S  GUIDE 


BY 

EDWARD  NETTLESHIP,  F.R.C.S. 

OPHTHALMIC  SURGEON   TO  ST.  THOMAS'  HOSPITAL,  AND  TO   THE   HOSPITAL 
FOR  SICK  CHILDREN,  GREAT  ORMOND  STREET. 

SECOND  AMERICAN 

FROM  THE 

SECOND  REVISED  AND  ENLARGED  ENGLISH  EDITION. 
WITH  A  CHAPTER  ON 

EXAMINATION  FOR  COLOR  PERCEPTION, 

BY 

WILLIAM  THOMSON,  M.D., 

PROFESSOR  OF  OPHTHALHOLOGY  IN  THE  JEFFERSON  MEDICAL  COLLEGE. 


PHILADELPHIA: 
HENRY    C.    LEA'S    SON   &    CO. 

1883. 


Entered  according  to  Act  of  Congress  in  the  year  1883,  by 

HENKY    C.   LEA'S   SON   &   CO., 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PORN  AN,     PRINTKR. 


TO 


JONATHAN  HUTCHINSON, 

CONSULTING  SURGEON  TO  THE  MOORFIELDS  OPHTHALMIC  HOSPITAL, 
.SKNIOR  SURGEON  TO  THE  LONDON  HOSPITAL,  ETC., 

THIS 
BOOK  IS  DEDICATED 

IN  GRATEFUL  ADMIRATION  OF  HIS  EMINENT  QUALITIES  AS  A 
ri.INICAL   TEACHER   AND    INVESTIGATOR. 


AMERICAN  PUBLISHER'S  PREFACE. 


IN  presenting  to  the  medical  profession  the  second 
American  edition  of  Dr.  Nettleship's  "  Guide  to  Diseases 
of  the  Eye,"  the  publishers  desire  to  state  that  no  pains 
have  been  spared  to  place  it  in  every  particular  upon 
a  level  with  the  latest  developments  of  the  specialty 
of  which  it  treats. 

In  addition  to  a  most  thorough  and  careful  revision 
by  the  author,  comprising  many  important  changes  and 
additions,  there  has  been  inserted  a  chapter  upon  the 
Detection  of  Color-blindness  from  the  pen  of  Dr.  William 
Thomson,  whose  painstaking  investigations  upon  this 
subject  are  widely  known. 

In  the  matter  of  illustrations,  several  engravings  from 
the  previous  edition  have  been  omitted,  as  deficient  in 
perspicuity,  and  new  ones,  to  about  the  number  of  fifty, 
inserted.  Every  care  has  been  taken  with  the  typog- 
raphy, and  in  all  respects  the  publishers  feel  assured 
that  the  work  will  be  found  to  merit  in  an  increased 
degree  the  confidence  awarded  by  the  profession  to  the 
previous  edition. 

PHILADELPHIA,  1883. 

(vii) 


PREFACE  TO  THE  SECOND  EDITION. 


THE  first  Edition  has  been  out  of  print  for  more  than 
six  months,  but  I  have  been  unable  sooner  to  prepare  a 
new  one. 

Every  page  of  the  book  has  been  carefully  revised,  much 
new  matter  incorporated,  and  many  faulty  and  needless 
passages  struck  out.  The  book  contains  about  twenty-two 
pages  more  than  it  did. 

The  following  are  the  most  important  changes  and  addi- 
tions : 

Chapter  I.,  on  Symptoms,  in  the  first  Edition  has  been 
replaced  by  a  chapter  on  "Optical  Outlines,"  which,  I 
believe,  will  be  more  useful  to  students. 

The  "  Functional "  Disorders  of  Sight  have  been  placed 
in  a  separate  chapter  (XV.),  instead  of  being  divided,  as 
in  the  first  Edition,  between  Diseases  of  the  Optic  Nerve 
and  Diseases  of  the  Retina. 


X  PREFACE. 

New  woodcuts  to  the  number  of  forty-eight  have  been 
added,  and  several  of  the  old  ones,  which  were  too  large 
for  a  book  of  this  size,  have  been  recut  on  a  smaller  scale ; 
one  or  two  have  been  omitted. 

I  have  to  thank  Mr.  J.  B.  Lawford  and  Mr.  E.  C.  Green 
for  much  help  in  seeing  the  book  through  the  press. 

June,  1882. 


CONTENTS. 


PAKT  I— MEANS  OF  DIAGNOSIS. 


PAGB 


LIST  OF  ABBREVIATIONS, 13 

CHAPTEK  I. 
OPTICAL  OUTLINES. 

Lenses  and  prisms  ;  Refraction  of  the  eye ;  Numeration  of 
spectacle  lenses ;  Table  showing  the  equivalent  numbers 
of  lenses  made  by  the  inch  scale  and  metrical  scale  re- 
spectively,    13-29 

CHAPTER  II. 

EXTERNAL  EXAMINATION  OF  THE  EYE. 
Examination  of:  (1)  Surface  of  cornea;  (2)  Tension  of  eye; 
(3)  Mobility  of  eye;  (4)  Squint  or  strabismus;  (5)  Di- 
plopia;  (G)  Protrusion  and  enlargement  of  eye ;  (7)  Ex- 
ternal bloodvessels  of  eye;  (8)  Color  of  iris;  (9)  Pupils; 
(10)  Field  of  vision;  (11)  Acuteness  of  sight;  (12)  Ac- 
commodation; (13)  Apparent  size  of  objects;  (14)  Color- 
perception  ;  (15)  The  uses  of  prisms,  .  .  .  30-46 

[CHAPTER  III. 

EXAMINATION  FOR  COLOR-PERCEPTION. 

Instructions  for  examination  of  railway  employes  as  to  vision, 
color-blindness,  and  hearing  :  Acuteness  of  vision  ;  Range 
of  vision  ;  Field  of  vision  ;  Color-sense  ;  Hearing  ;  Ex- 
planations,    47-59] 

CHAPTER  IY. 
EXAMINATION  OF  THE  EYE  BY  ARTIFICIAL  LIGHT. 

(1)  Focal  or  "oblique"  illumination. 

(2)  Ophthalmoscopic  examination :  Indirect  examination;  Di- 

rect examination ;  Use  of  the  ophthalmoscope. 

(xi) 


xii  CONTENTS. 

PAGE 

Appearances  of  Optic  Disk;  scleral  ring,  physiological  pit, 
lamina  cribrosa:  of  choroid :  of  retina:  vessels,  yellow 
spot,/ot>e<z  centralis. 

Examination  of  vitreous ;  Determination  of  refraction ;  Ex- 
amination of  fine  details  by  direct  method. 

Retinoscopy  (Keratoscopy), 60-80 


PART  II— CLINICAL  DIVISION. 

CHAPTER  V. 
DISEASES  OF  THE  EYELIDS. 

Blepharitis ;  Stye ;  M  eibomian  cyst ;  Horns  and  warty  forma- 
tions; Molluscum  contagiosum;  Xanthelasma;  Pedicti- 
lus  pubis.  Ulcers:  Rodent  cancer;  Tertiary  syphilis; 
Lupus;  Chancre.  Congenital  ptosis ;  Epicanthus,  .  81-88 

CHAPTER  VI. 

DISEASES  OF  THE  LACHRYMAL  APPARATUS. 

Diseases  of  lachrymal  gland. 

Epiphora,  stillicidium  lacrymarum,  and  lachrymation. 
Epiphora  from  alterations  of  punctum  and  canaliculus. 
Diseases  of  lachrymal  sac  and   nasal  duct:     Mucocele  and 

lachrymal  abscess ;  Stricture  of  nasal  duct,        .         .       89-94 

CHAPTER  VII. 

DISEASES  OF  THE  CONJUNCTIVA. 

Ophthalmia:  Purulent  and  gonorrhceal  ophthalmia;  Muco- 
purulent  ophthalmia;  Catarrhal  ophthalmia  and  other 
mild  forms;  Membranous  and  diphtheritic  ophthalmia; 
Atropine  and  eserine  irritation ;  Granular  ophthalmia, 
Pannus.  Distichiasis,  and  Trichiasis,  Organic  entropion; 
Chronic  conjunctivitis, 95-109 

CHAPTER  VIII. 
DISEASES  OF  THE  CORNEA. 
A.  Ulcers  and  non-specific  inflammation. 

Appearances  of  the  cornea  in  disease:  "Steamy  "and 
"ground-glass"  cornea;  Infiltration  ;  Swelling;  Ulcera- 
tion ;  Nebula  and  leucoma. 


CONTENTS.  X1H 

PAGE 

Symptoms  in  ulceration :  Photophobia ;  Congestion  ; 
Pain. 

Clinical  types  of  ulcer:  Central  ulcer  of  children; 
Facetting  ulcer;  Phlyctenular  affections ;  Phlyctenular, 
or  recurrent]  vascular,  ulcer ;  Marginal  keratitis  (Spring- 
catarrh)  ;  Serpiginous  ulcer ;  Abscess  and  suppurating 
ulcer;  Hypopyon ;  Onyx. 

Conical  cornea. 
B.  Diffuse  keratitis. 

Syphilitic  keratitis.  Other  forms  of  keratitis:  Keratitis 
punctata ;  Cornea!  changes  in  glaucoma;  Calcareous  film  ; 
Arcus  senilis ;  Inflammatory  arcus ;  Opacity  from  use  of 
lead  lotion  ;  Staining  from  use  of  nitrate  of  silver,  .  110-133 

CHAPTER  IX. 

DISEASES  OF  THE  IRIS. 

Iritis.     Symptoms :     Muddiness    and    discoloration   of    iris  ; 
Synechias;    Corneal    haze;    Ciliary    congestion;    Pain; 
Lymph-nodules ;  Hypopyon. 
Results  of  iritis. 

Causes:  Syphilis;  Rheumatism;  Gout;  Sympathetic 
disease;  Injuries.  Chronic  iritis. 

Congenital  irideremia ;  Coloboma ;  Persistent  pupillary  mem- 
brane,    134-144 

CHAPTER  X. 

DISEASES  OF  THE  CILIARY  REGIOX. 

Episcleritis,  Sclero-keratitis,  and  allied  diseases;  Cyclitis 
(irido-choroiditis) ;  "  Idiopathic  phthisis  bulbi ;"  Trau- 
matic cyclitis. 

Sympathetic  affections :  Sympathetic  irritation  ;  Sympathetic 

inflammation, 145-157 

CHAPTER  XI. 

INJURIES. 

A.  Of  the  parts  around  the  eyeball. 

Contusions  and  concussions:  Black  eye;  Ecchymosis 
from  fracture  of  orbit;  Emphysema  of  orbit;  Ptosis. 
Orbital  cellulitis  and  abscess. 


XIV  CONTENTS. 

PAGB 

Wounds  of  the  eyelids.     Deep  wounds  of  orbit.     For- 
eign bodies  in  orbit;  Gunshot  wounds  of  orbit. 
B.  Injuries  of  the  eyeball. 

Contusion  and  concussion  injuries:  Rupture;  Intra- 
ocular hemorrhage ;  Detachment  of  iris ;  Dislocation  of 
lens;  Detachment  of  retina;  Rupture  of  choroid;  Pa- 
ralysis of  iris  and  ciliary  muscle;  Commotio  retinae; 
Traumatic  myopia. 

Surface  wounds  of  eyeball :  Abrasion  and  foreign  body 
on  cornea;  Foreign  body  on  conjunctiva. 

Burns  and  scalds ;  Lime-burn;  Serious  results  of  severe 
burns. 

Penetrating  wounds  of  eyeball:  Slight  cases.  Severe 
cases ;  Traumatic  cataract ;  Cyclitis ;  Foreign  body  in  eye. 
Treatment:  Eules  as  to  the  excision  of  wounded  eyes. 
Electro-magnet  for  removing  bits  of  iron,  .  .  138-170 

CHAPTER  XII. 

CATARACT. 
Definition :   Senile  changes  in  lens. 

General  cataract:  Nuclear  and  cortical,  each  may  be 
hard  (senile)  or  soft  (juvenile) ;  Congenital ;  Concussion  ; 
Traumatic.  Partial  cataract :  Lamellar ;  Pyramidal ; 
Posterior  polar. 

Primary  and  secondary  cataract. 
Symptoms  and  diagnosis  of  cataract.     Prognosis. 
Treatment:  Extraction;  Discission  or  solution  ;  Suction. 

Causes  of  failure  after  extraction  :  Hemorrhage ;  Sup- 
puration of  cornea;  Iritis  ;  Prolapse  of  iris. 
Sight  after  removal  of  cataract. 

Treatment  of  lamellar  cataract. 
Dislocation  of  the  lens, 171-187 

CHAPTER  XIII. 

DlSKASES    OF    THE    CHOROID. 

Participation  by  the  retina. 

Appearances  in  health  and  disease:    Atrophy;  Pigment  in 

choroid  and  retina ;  Exudations,  syphilitic,  tubercular  ; 

Rupture;  "  Colloid  "  change ;  Hemorrhages. 


CONTENTS.  XV 

PAGE 

Clinical  forms  of  disease :  Choroiditis  disseminata,  Syphilitic 
choroiditis  ;  Myopic  changes  ;  Central  senile  choroiditis  ; 
Anomalous  forms. 

Coloboma;  Albinism, 188-202 

CHAPTER  XIY. 
DISEASES  OP  THE  RETINA. 

Appearances  in  health:  Bloodvessels,  yellow  spot,  and 
"  halo  "  around  it;  Opaque  nerve-fibres. 

Appearances   in   disease:     Congestion;    Retinitis,  (1) 
Diffuse,  (2)  and  (3)  Localized,  with  white  spots. 
Hemorrhage ;  Pigmentation ;  Atrophy  ;  Disk  in  atrophy  of 
retina;  Detachment.     Single. patch  of  retinitis  caused  by 
choroiditis. 

Clinical  forms  of  disease  :  Syphilitic  retinitis ;  Albuminuric  ; 
Hemorrhagic ;  Retinitis  apoplectica  and  large  single 
hemorrhages ;  Embolism  and  thrombosis  ;  Retinitis  pig- 
mentosa, 203-223 

CHAPTER  XV. 

DISEASES  OF  THE  OPTIC  NERVE. 

Relation  between  changes  at  the  Disk,  disease  of  the  Optic 
Nerve,  and  affection  of  Sight. 

Pathological  changes  in  optic  nerve. 

Appearances  of  optic  disk  in  disease  :  Inflammation,  optic 
neuritis,  papillitis,  or  choked  disk ;  Atrophy  after  papil- 
litis ;  Papillo-retinitis. 

Etiology  of  papillitis.  Retrobulbar  neuritis  ;  Syphilis 
causing  papillitis.  The  pupils  in  neuritis. 

Atrophy  of  disk :  Appearances  and  causes  ;  Clinical 
aspects;  State  of  sight,  field  of  vision,  and  color-percep- 
tion ;  A.  Double  atrophy  ;  B.  Single  atrophy,  .  224-237 

CHAPTER  XVI. 

AMBLYOPIA  AND  FUNCTIONAL  DISORDERS  OF  SIGHT. 
"Amblyopia"     and    "Amaurosis:"     Single      Amblyopia : 

From  suppression  ;    from  defective  images  ;  from  retro- 

bulbar  neuritis ;  Double  Amblyopia  :  Central  Amblyopia 

(Tobacco  amblyopia). 
Hemianopsia ;  Hysterical  amblyopia  and  Hyperassthesia  oculi  ; 

Asthenopia. 


XVI  CONTENTS. 

PAGE 

Functional  diseases  of  retina;  Endemic  nyctalopia  ;  Hemeral- 
opia  ;  Micropsia ;  Muscae  volitantes  ;  Diplopia  ;  Malin- 
gering ;  Color-blindness, 238-250 

CHAPTER  XVII. 

DISEASES  OF  THE  VITREOUS  HUMOR. 
Usually  secondary  to  other  diseases  of  Eye. 

Examination     for    opacities :     Cholesterine  ;      Blood ; 
Bloodvessels  in  vitreous  ;   Cysticercus. 

Conditions  causing  disease  of  vitreous  :  Myopia  ;  Blows  and 
wounds  ;  Spontaneous  hemorrhage ;  Cyclitis,  choroiditis, 
and  retinitis ;  Glaucoma, 251-255 

CHAPTER  XVIII. 

GLAUCOMA. 

Primary  and  secondary. 

Primary  glaucoma :     Premonitory  stage  ;  Chronic  ;  Simple  ; 
Subacute ;  Acute ;  Absolute  ;  Glaucoma  fulminans. 
Ophthalmoscopic  changes  ;    Cupping  of  disk. 
Symptoms  explained  ;  Mechanism  ;  General  and  dia- 
thetic  causes  ;  Treatment ;  Prognosis. 
Secondary  glaucoma ;  Conditions  causing  it, .         .         .     256-274 

CHAPTER  XIX. 

TUMORS  AND  NEW  GROWTHS. 

A.  Of  the  eyelids  (see  also  Chapter  V.).     Naevus;  Dermoid 

cyst. 

B.  Of  the  conjunctiva  and  front  of  the  eyeball.     Cauliflower 

wart ;  Lupus ;  Syphilitic  infiltration  of  lid ;  Pinguecula  ; 
Pterygium  ;  Thin  cysts  ;  Dermoid  tumor  ;  Episcleritis 
simulating  tumor  •  Fibro-fatty  growth  ;  Cystic  tumors  ; 
Epithelioma;  Sarcoma. 

C.  Orbital  tumors.     Tumors  encroaching  on  the  orbit  from 

other  parts:  Distention  of  frontal  sinus;  Ivory  exostosis. 
Pulsating  tumors ;  Fluctuating  and  cystic  tumors.  Solid 
tumors  limited  to  orbit :  Periosteal  tumors ;  Lachrymal 
gland  tumors;  Tumors  of  optic  nerve;  Other  forms; 
Syphilitic  nodes. 

D.  Intraocular   tumors.     Glioma  of  retina ;   Pseudo-glioma. 

Sarcoma  of  choroid ;  Tubercular  tumor  of  choroid ; 
Tumors  of  iris  :  Sarcoma ;  Sebaceous  tumor ;  Cysts ; 
Granuloma, 275-286 


CONTENTS.  XV11 

CHAPTEE  XX. 
ERRORS  OF  REFRACTION  AND  ACCOMMODATION. 

PAGE 

Emmetropia ;  Ametropia  ;  Accommodation. 

Myopia.  Symptoms ;  Insufficiency  of  internal  recti ;  Pos- 
terior staphyloma  and  crescent ;  Other  complications. 
Causes  ;  Tests  for  ;  Measurement  of  degree  ;  Treatment ; 
Spectacles;  Tenotomy, 287-299 

Hypermetropia.  Symptoms:  Accommodative  asthenopia; 
Convergent  strabismus.  Tests  for  hypermetropia.  Treat- 
ment: Spectacles.  Treatment  of  the  strabismus,  .  299-307 

Astigmatism.     Kegular  and  irregular  ;  Seat ;  Focal  interval  ; 
Cylindrical  lenses;   Forms  of  regular  astigmatism;  De- 
tection and  measurement ;  Spectacles,      .         .         .    307-317 
Unequal  refraction  in  the  two  eyes. 

Presbyopia :     Eate  of  progress  ;    Treatment,  .         .         .     317-319 

CHAPTEE  XXL 
STRABISMUS  AND  PARALTSIS. 

Definition  of  strabismus ;  Diplopia ;  True  and  false  image ; 
Homonymous  and  crossed  diplopia ;  Suppression  of  false 
image. 

Causes  :  Strabismus  from  over-action ;  from  weakness  ;  from 
disuse ;  from  weakness  following  tenotomy ;  from  pa- 
ralysis. 

Paralysis  of  sixth  nerve  (external  rectus) ;  of  fourth  nerve 
(superior  oblique) ;  of  third  nerve.  Primary  and  secon- 
dary strabismus  ;  Giddiness  in  paralytic  strabismus. 

Paralysis  of  internal  muscles  of  eye :  Iris  alone  ;  Ciliary 
muscle  alone  ;  Both  iris  and  ciliary  muscle. 

Causes  of  external  ocular  paralyses :  Syphilitic  growths  ; 
Meningitis;  Tumors;  Eheumatism.  Causes  of  internal 
ocular  paralyses. 

Nystagmus, 320-332 

CHAPTEE  XXII. 

OPERATIONS. 
A.  On  the  eyelids. 

Epilation;  Eversion  of  lid  ;  Meibomian  cyst ;  Inspec- 
tion of  cornea ,  Spasmodic  entropion  ;  Organic  entropion 
and  trichiasis  ;  Ectropion  ;  Canthoplasty ;  Peritomy ; 
Ptosis.  B* 


XV111  CONTENTS. 

PAGE 

B.  On  the  lachrymal  apparatus. 

Lachrymal  abscess;  Slitting  canaliculus ;  Stricture  of 
nasal  duct,  (1)  Probing,  (2)  Incision. 

C.  For  strabismus. 

Tenotomy  :  Critchett's  ;  Liebreich's.     Readjustment. 

D.  Excision  and  abscission  of  the  eye.     Optico-ciliary  neu- 

rotomy. 

E.  On  the  cornea. 

Foreign  body  ;  Paracentesis ;  Corneal  section  (Sae- 
misch's  operation) ;  Conical  cornea. 

F.  On  the  iris. 

Iridectomy  :  for  artificial  pupil ;  for  glaucoma  ;  Irido- 
desis  ;  Iridotomy  (iritomy). 

Sclerotomy. 
Gr.  For  cataract. 

Extraction:  Linear;  Graefe's  "modified  linear;" 
Corneal  section  (Liebreich,  Lebrun) ;  Short  flap ;  Old 
flap.  Treatment  after  extraction.  Secondary  operations. 
Discission  or  solution;  Suction.  Treatment  after  solu- 
tion and  suction, 333-372 


PART  III.— DISEASES  OF  THE  EYE  IN  RELA- 
TION TO  GENERAL  DISEASES. 

CHAPTER  XXIII. 
A.   GENERAL  DISEASES. 

Eye  diseases  caused  by:  Syphilis,  acquired  or  inherited,  dis- 
eases of  optic  nerve  in  relation  to  syphilis  ;  Smallpox  ; 
Scarlet  fever,  typhus,  etc.;  Diphtheria  ;  Measles ;  Chicken- 
pox  and  whooping-cough  ;  Malarial  fevers ;  Relapsing 
fever;  Epidemic  cerebro-spinal  meningitis;  Purpura 
and  scurvy  ;  Pyaemia  and  septicaemia  ;  Lead  poisoning  ; 
Alcohol;  Tobacco  ;  Quinine  ;  Kidney  disease  ;  Diabetes; 
Leucocythaemia ;  Pernicious  anaemia ;  Heart  disease ; 
Tuberculosis;  Rheumatism  and  gonorrhoeal  rheumatism  ; 
Gout,  personal  and  inherited  ;  Struma  ;  Entozoa. 


CONTENTS.  XIX 

B.  LOCAL  DISEASE  AT  A  DISTANCE  FROM  THE  EYE. 

PAGB 

Eye  symptoms  caused  by  :  Megrim  ;  Neuralgia  ;  Diseases  of 
brain;  Cerebral  tumor;  Syphilitic  disease ;  Meningitis; 
Cerebritis ;  Hydrocepbalus ;  Convulsions.  Diseases  of 
spinal  cord  ;  Myelitis ;  Locomotor  ataxia.  General  pa- 
ralysis of  insane.  Motor  disorders  of  eyes  and  affections 
of  the  pupils  in  cerebral  and  spinal  disease. 

c.  THE  EYE  SHARING  IN  A  LOCAL  DISEASE  OF  THE 
NEIGHBORING  PARTS. 

Eye  symptoms  caused  by  :  Herpes  zoster  of  fifth  nerve ; 
Paralysis  of  fifth,  of  facial,  and  of  sympathetic  nerves; 
Exophthalmic  goitre ;  Erysipelas  and  orbital  cellu- 
litis, 373-396 

Appendix:  Formulae,  etc.,       ......     397-402 

Index, ,     403-416 


PART  I. 


MEANS  OF  DIAGNOSIS. 


THE  following  abbreviations  will  be  used  in  this  work : 


T.    Tension  of  the  eyeball. 

E.    Emmetropia. 

M.  Myopia. 

H.    Hypermetropia. 

H.  m.    Manifest    hypermetro- 

pia. 

H.  1.  Latent  hyperraetropia. 
Pr.  Presbyopia. 
As.  Astigmatism. 
A.    Accommodation. 
V.    Acuteness  of  vision. 
p.      Punctum    proximum,    or 
near  point. 


p.l. 
P. 


m. 
cm. 
mm 
D. 


Punctum  remotum,  or  far 
point. 

Perception  of  light. 

Pupil. 

Sign  for  a  foot. 

Sign  for  an  inch. 

Metre. 

Centimetre. 

Millimetre. 

Dioptre,  the  unit  in  the 
metrical  system  of  mea- 
suring lenses. 

Yellow  spot  of  the  retina. 


CHAPTER  I. 

OPTICAL    OUTLINES. 

1.  RAYS  of  light  are  deviated  or  refracted  when  they 
pass  from  one  transparent  medium,  e.  g.,  air,  into  another 
of  different  density,  e.  g.,  water  or  glass. 

2.  If  the  deviation  in  passing  from  vacuum  into  air  be 
represented  by  the  number  1,  that  for  crown  glass  (of 
which  ordinary  lenses  are  made)  is  1.5  and  for  rock  crys- 
tal ("pebble"  of  opticians)  1.66.     Each  of  these  numbers 
is  the  "  refractive  index  "  of  the  substance.     Every  ray  is 
refracted  except  the  one  which  falls  perpendicularly  to  the 

surface  (Fig.  1,  a). 

2  (13) 


14 


OPTICAL    OUTLINES. 


3.  In  passing  from  a  less  into  a  more  refracting  medium 
the  deviation  is  always  towards  the  perpendicular  to  the 
refracting  surface;  in  passing  from  a  more  into  a  less  re- 
fracting medium  it  is  always  and  to  the  same  extent  away 
from  the  perpendicular  (Fig.  1,  6),  i.  e.,  the  angle  x  in  the 
figure  =  the  angle  y, 

4.  Hence,  if  the  sides  of  the  medium  (Fig.  1,  m)  be  par- 
allel, the  rays  on  emerging  (£>')  are  restored  to  their  original 


FIG.  1. 


Refraction  by  a  medium  with  parallel  sides. 

direction  (6),  and  if  the- medium  be  thin  very  nearly  to  their 
original  path. 


FIG.  2. 


Refraction  by  a  prism. 

5.  But  if,  as  in  a  prism,  the  sides  of  m  form  an  angle 
(Fig.  2,  a)  the  angles  of  incidence  and  emergence  (a;  and  y), 


OPTICAL     OUTLINES.  15 

still  being  equal,  b'  must  also  form  an  angle  with  b.  The 
angle  a  is  the  ''refracting  angle"  or  edge;  the  opposite  side 
is  the  "  base."  The  figure  shows  that  light  is  always  devi- 
ated towards  the  base.  Crown  glass  prisms  cause  a  deviation 

FIG.  3. 


Apparent  displacement  of  object  by  a  prism. 

(represented  by  the  angle  d)  equal  to  about  half  the  re- 
fracting angle  of  the  prism.  The  relative  direction  of  the 
rays  is  not  changed  by  a  prism ;  if  parallel  or  divergent 
before  incidence,  they  are  parallel  or  similarly  divergent 
after  emergence  (Fig.  3). 

FIG.  4. 


Refraction  the  same  for  different  angles  of  incidence. 

6.  Every  object  seems  to  lie,  or  is  "projected,"  in  the  di- 
rection of  the  rays  as  they  enter  the  eye;  ob  (Fig.  3),  seen 


16  OPTICAL     OUTLINES. 

by  an  eye  at  a'  or  b',  seems  to  be  at  ob',  where  it  would  be 
if  the  rays  a'  b'  came  from  it  without  deviation. 

7.  For  very  thin  prisms  the  deviation  (a  and  p,  Fig.  4) 
remains  the  same  for  varying  angles  of  incidence.  For  thin 
lenses  this  is  expressed  by  saying  that  the  angle  d,  Fig.  5, 


Refraction  by  a  lens  the  same  for  all  rays  incident  at  same  distance 
from  axis. 

is  the  same  for  the  rays  a  a',  b  b',  and  c  c' ,  incident  at  differ- 
ent angles,  but  at  the  same  distance  from  the  axis. 

8.  An  ordinary  lens  is  a  segment  of  a  sphere  (plano-con- 

FIG.  6. 


Prismatic  elements  of  a  convex  lens. 

vex  or  plano-concave),  or  of  two  spheres  whose  centres  are 
joined  by  the  axis  of  the  lens  (biconvex  or  biconcave). 

9.  A  lens  is  regarded  as  formed  of  an  infinite  number  of 
minute  prisms,  each  with  a  different  refracting  angle.  Fig. 
6  shows  two  such  elements  of  a  convex  lens,  in  which  the 


OPTICAL     OUTLINES.  17 

angle  (a)  of  the  prism  at  the  edge  of  the  lens  is  larger  than 
the  angle  (/?)  of  the  prism  nearer  the  axis.  Hence,  of  the 
two  parallel  rays  (a  and  b~),  a  will  (see  §  5)  be  more  refracted 
than  b,  and  the  rays  will  after  emergence  converge  and  meet 
at  /.  Fig.  7  shows  the  corresponding  facts  for  a  concave 
lens,  by  which  parallel  rays  are  made  divergent. 

FIG.  7. 


Prismatic  elements  of  a  concave  lens. 

10.  The  only  ray  not  refracted  by  a  lens  is  the  one  pass- 
ing through  the  centre  of  each  surface  (compare  §  2), 
which  is  the  principal  axis  (ax,  Fig.  8).  Secondary  axes  are 


FIG.  8. 


Axes  of  a  lens. 

rays  (such  as  s.  ax)  entering  and  emerging  at  points  on  the 
lens  parallel  to  each  other,  and  hence  (see  §  4)  hardly 
altered  in  course ;  in  practice  they  are  all  rays  (except  the 
principal  axis)  which  pass  through  the  central  point  oi 
the  lens. 

11.  The  principal  focus  (/,  Fig.  9)  of  a  lens  is  the  point 
2* 


18 


OPTICAL    OUTLINES. 


to  which  rays  parallel  before  incidence  (a  a)  converge 
after  refraction,  the  deviation  of  each  ray  varying  directly 
with  its  distance  from  the  principal  axis  (Fig.  6).  If  par- 
allel rays  are  incident  from  the  side  towards/,  they  will  be 
focussed  at  /',  at  the  same  distance  from  the  lens  as/; 
hence  every  lens  has  two  principal  foci — anterior  and. 
posterior. 

12.  The  path  of  a  ray  passing  from  one  point  to  another 
is  the  same,  whatever  its  direction;  the  path  of  the  ray  bb' 

FIG.  9. 


Foci  of  a  convex  len?. 

is  the  same,  whether  it  pass  from  cf  to  c'f,  or  in  the  oppo- 
site direction. 

13.  From  §  7  it  follows  that  in  Fig.  9  the  angles  a  and 

FIG.  10. 


Foci  of  a  concave  lens. 


a  are  equal,  and  hence  the  ray  b,  diverging  from  cf,  will 
not  meet  the  axis  at/,  but  at  c'f',  cf  and  c'f  are  conjugate 
points,  and  each  is  the  conjugate  focus  of  the  other.  The 


OPTICAL     OUTLINES.  19 

angle  a  or  a'  remaining  the  same,  then  if  c/"be  further  from 
the  lens  c'f  will  approach  it.  A  ray  (c)  converging  to  the 
axis  will  be  focussed  at  c"f",  because  a"  =  a ;  no  real  point 
conjugate  to  c"f"  exists;  but  if  the  ray  start  from  c"f"  it 
will,  on  taking  the  direction  c,  appear  to  come  from  vf, 
which  is  the  virtual  focus  of  c"f"  (see  §  6). 

14.  Concave  lenses  have  only  virtual  foci.     In  Fig.  10, 
a,  parallel  to  the  axis,  is  made  divergent  (see  Fig.  7),  and 
has  its  virtual  focus  at  /,  and  cf  is  similarly  the  virtual  con- 
jugate focus  of  6. 

15.  In  equally  biconvex  or  biconcave  lenses  of  crown 
glass  the  principal  focus  is  at  the  centre  of  curvature  of 
either  surface  of  the  lens. 

16.  Images. — The  image  formed  by  a  lens  consists  of 
foci,  each  of  which  corresponds  to  a  point  on  the  object. 
Given  the  foci  of  the  boundary  points  of  an  object,  we 
have  the  position  and  size  of  its  image. 

In  Fig.  11  the  object  a  b  lies  beyond  the  focus/.     From 

FIG.  11. 


Real  inverted  image  formed  by  a  convex  lens. 

the  terminal  point  a  take  two  rays  a  and  a,  the  former 
a  secondary  axis,  and  therefore  unrefracted;  the  other 
parallel  to  the  principal  axis,  and  therefore  passing  after 
refraction  through  the  principal  focus/'.  These  two  rays 
(and  all  others  which  pass  through  the  lens  from  the  point 
a)  will  meet  at  A,  the  conjugate  focus  of  a.  Similarly  the 


20  OPTICAL    OUTLINES. 

focus  of  the  other  end  of  a  b  is  found,  and  the  real  inverted 
conjugate  image  of  a  b  is  formed  at  A  B.  The  relative 
sizes  of  a  b  and  A  B  vary  as  their  distances  from  the  lens. 

If  a  6  be  so  far  off  that  its  rays  are  virtually  parallel  on 
reaching  the  lens,  its  image  A  B  will  be  at/',  and  very 
small.  If  a  b  be  at  /  its  rays  will  be  parallel  after  refrac- 
tion (§  12),  and  no  image  be  formed.  If  a  b  lie  between 
/  (or/')  and  the  lens,  the  rays  will  diverge  after  refraction, 
and  again  no  image  be  formed  (see  Fig.  9,  c'/"). 

But  in  the  two  last  cases  a  virtual  image  is  seen  by  an 
eye  so  placed  as  to  receive  the  rays.  In  Fig.  12  two  rays 
from  a  take  after  refraction  the  course  shown  by  o  and  a', 
virtually  meeting  at  A  (see  Fig.  9,  vf ) ;  and  an  eye  at  x 
will  see  at  A  B  a  virtual,  magnified,  erect  image  of  a  b. 

The  enlargement  is  greater  the  nearer  a  b  is  to  /,  and 
greatest  when  it  is  at/.  But,  as  A  B  has  no  real  existence, 

FIG.  12. 


Virtual  erect  image  formed  Vr  a  CODTCZ  lens. 

its  apparent  size  varies  with  the.  known  or  estimated  dis- 
tance of  the  surface  against  which  it  is  projected.  A  uni- 
form distance  of  projection  of  about  12"  (30  cm.)  is  taken 
in  comparing  the  magnifying  power  of  different  lenses. 

When  a  b  is  at/  it  will  be  found  on  trial  that  the  image 
A  B  can  be  seen  well  only  by  bringing  the  eye  close  up  to 
the  lens.  At  a  greater  distance  only  part  of  the  object  will 
be  seen,  and  it  will  be  less  brightly  lighted,  facts  which  are 


OPTICAL     OUTLINES. 


21 


important  in  direct  ophthalmoscopic  examination  (p.  75 
In  Fig.  13  an  eye  placed  anywhere  between  the  lens  and  x 


Fro.  13. 


Virtual  image;  result  of  observer  varying  distance  of  bis  eye 
from  the  lens. 

will  receive  rays  from  every  part  of  a  b,  and  therefor^ 
the  whole  image.     But  if  the  observer  be  at  y,  his  eye  will 
receive  rays  only  from  the  central  part  of  a  b,  and  will 
therefore  not  see  the  ends  of  the  object. 

By  similar  constructions  it  is  easily  shown  that  the 
images  formed  by  concave  lenses  are  always  virtual,  erect, 
and  diminished,  whatever  the  distance  of  the  object  (Tig. 
14  i.  (Compare  Fig.  10.) 

Fie.  14. 


Image  formed  by  a  concave  lens. 

17.  The  size  of  the  image  (whether  real  or  virtual)  varies 
with  (1)  the  focal  length  of  the  lens,  and  (2)  the  distance 
of  the  object  from  the  principal  focus. 

(1)  The  shorter  the  focus  of  the  lens,  the  greater  is  its 
effect  or  the  "  stronger  "  it  is  ;  the  refractive  power  of  a  lens 
varies  inversely  as  its  focal  length. 


22  OPTICAL     OUTLINES. 

(2)  For  a  convex  lens,  the  image  (whether  real  or  vir- 
tual) is  larger  (i.  e.,the  effect  greater)  the  nearer  the  object 
is  to  the  principal  focus  (whether  within  or  beyond  it). 

For  a  concave  lens  the  image  is  smaller  (i.  e.,  the  effect 
greater)  the  further  the  object  is  from  the  lens  (whether 
within  or  beyond  the  focus). 

18.  Prisms. — An  object  appears  displaced  towards  the 
edge  of  a  prism  through  Avhich  it  is  seen,  and  to  a  degree 
which  varies  directly  as  the  size  of  the  refracting  angle 
(§§  5  and  6).  The  observer,  looking  through  the  prism, 
directs  his  eye  to  the  object  in  its  apparent  position  (§  G), 
and  this  fact  may  be  utilized  for  several  purposes :  1.  To 
lessen  the  convergence  of  the  visual  lines  without  removing 

FIG.  15. 


Effect  of  prisms  in  lesesnlng  convergence. 

the  object  further  from  the  eyes.  In  Fig.  15  the  eyes,  R 
and  L,  are  looking  at  the  object  (06)  with  a  convergence 
of  the  visual  lines  represented  by  the  angle  a.  If  prisms 
be  now  added  with  their  bases  towards  the  nose  they  de- 


OPTICAL    OUTLINES.  23 

fleet  the  light,  so  that  it  enters  the  eyes  under  the  smaller 
angle  (3,  as  if  it  had  come  from  (06'),  and  towards  this  point 
the  eyes  will  be  directed,  though  the  object  still  remains 
at  ob.  The  same  effect  is  given  by  a  single  prism  of  twice 
the  strength  before  one  eye,  though  the  actual  movement 
is  then  limited  to  the  eye  in  question.  If  spectacle  lenses 
be  placed  so  that  the  visual  lines  do  not  pass  through  their 
centres,  they  act  as  prisms,  though  the  strength  of  the 
prismatic  action  varies  with  the  power  of  the  lens  and  the 
amount  of  this  "  decentration "  (see  §9,  Figs.  6  and  7). 
In  Fig.  16  the  visual  lines  pass  outside  the  centres  of  the 

FIG.  16. 


Lenses  acting  as  prisms. 

convex  lenses  (a)  and  inside  those  of  the  concave  lenses 
(6).  Each  pair,  therefore,  acts  as  a  prism  with  its  base  in- 
wards. 2.  To  remove  double  vision  caused  by  slight  degrees 
of  strabismus.  The  prism  so  alters  the  direction  of  the  rays 
as  to  compensate  for  the  abnormal  direction  of  the  visual 
line.  In  Fig.  17,  R  is  directed  towards  x  instead  of  towards 


•24 


OPTICAL    OUTLINES. 


ob,  and  two  images  of  ob  are  seen.  The  prism  (p)  deflects 
the  rays  on  to  y,  the  yellow  spot,  and  singular  binocular 
vision  is  the  result  3.  To  te$t  the  strength  of  the  ocular 
muscles.  In  Fig.  18  the  prism  at  first  causes  diplopia  by 
displacing  the  rays  from  the  yellow  spot  (y)  of  the  eye  (R) 

Fra.  17. 


Diplopia  removed  by  prism. 


Prism  used  for  testing  strength 
of  muscle. 


(_Chap.  XXI.).  By  a  compensating  rotation  of  the  eye 
(cornea)  outwards,  shown  in  the  figure  by  the  change  of  the 
transverse  axis  from  1  to  2,  y  is  brought  inwards  to  the 
situation  of  tin,  the  images  are  fused  and  single  vision  re- 
stored ;  the  effect  of  the  prism  is  overcome  by  the  action 
of  the  external  rectus.  This  "fusion  power"  of  the  several 
pairs  of  muscles  may  be  expressed  by  the  strongest  prism 
that  each  pair  can  overcome.  The  fusion  power  of  the  two 
external  recti  is  represented  by  a  prism  of  about  8° ;  that 
of  the  two  internals  by  25°  to  35°,  or  more ;  that  of  the 
superior  and  inferior  recti,  acting  against  each  other  by 


OPTICAL     OUTLINES.  25 

only  about  3°.  4.  Feigned  blindness  of  one  eye  may  often  be 
exposed  by  means  of  the  diplopia  (unexpected  by  the  pa- 
tient) produced  by  a  prism.  The  prism  should  be  stronger 
than  can  be  overcome  by  any  effort,  e.  g.,  8°  or  10°,  base 
upwards  or  downwards.  The  patient  is  often  best  thrown 
off  his  guard  by  holding  the  prism  before  the  sound  eye. 
If  he  now  exclaims  that  he  sees  double,  he  must  of  course 
be  seeing  with  both  eyes. 

19.  Refraction  of  the  eye. — The  eye  presents  three  re- 
fracting surfaces :  the  front  of  the  cornea,1  the  front  of  the 

FIG.  19. 


Visual  angle.     Size  of  retinal  image  in  H.  (curved  line  nearest  to  ti), 
in  E.  (middle  thin  line),  and  M.  (line  furthest  from  n). 

lens,  and  the  front  of  the  vitreous ;  and  in  the  normally 
formed  or  emmetropic  eye,  with  the  accommodation  re- 
laxed, the  principal  focus  (§  11)  of  these  combined  diop- 
tric media  falls  exactly  upon  the  layer  of  rods  and  cones 
of  the  retina,  i.  e.,  the  eye  in  a  state  of  accommodative  rest 
is  adapted  for  parallel  rays.  The  point  at  which  the  sec- 
ondary axial  rays  (see  §  10,  Fig.  8)  cross  the  "posterior 
nodal  point"  (n,  Fig.  19)  lies  in  the  normally  formed  eye 
at  15  mm.  in  front  of  the  yellow  spot  of  the  retina,  and 

1  The  posterior  surface  of  the  cornea  being  parallel  with  the 
anterior,  causes  no  deviation ;  and  the  refractive  power  of  the 
aqueous  is  the  same  as  that  of  the  cornea.  Hence  the  refractive 
effect  of  the  cornea  and  aqueous  is  the  same  as  if  the  corneal  tissue 
extended  from  the  front  of  the  cornea  to  the  front  of  the  lens. 

3 


26  OPTICAL     OUTLINES. 

very  nearly  coincides  with  the  posterior  pole  of  the  crys- 
talline lens.  The  angle  included  between  the  lines  joining 
n  with  the  extremities  of  the  object  (06)  is  the  visual  angle 
(v).  If  the  distance  (d),  from  n  to  the  retina,  remain  the 
same,  the  size  of  Im  will  depend  on  the  size  of  the  angle  v, 
which  will  depend  on  the  size  and  distance  of  ob.  But  if 
the  distance  (d)  alters  (v  remaining  the  game),  the  size  of 
the  retinal  image  (Im)  is  altered  without  any  change  in  v. 
Now  the  length  of  d  varies  with  the  length  of  the  posterior 
segment  of  the  eye;  it  is  increased  in  myopia  (M.)  and 
diminished  in  hypermetropia  (H.),  and  hence  the  retinal 
image  of  an  object  at  a  given  distance  is  larger  in  myopia 
and  smaller  in  hypermetropia  than  in  the  normally  formed 
eye.  The  length  of  d  depends  also  upon  the  position  of  n, 
and  this  is  influenced  by  the  positions  and  curvatures  of 
the  several  refractive  surfaces,  n  is  advanced  very  slightly 
by  the  increased  convexity  of  the  lens  during  accommoda- 
tion, but  much  more  so  if  the  same  change  of  refraction  is 
induced  by  a  convex  lens  held  in  front  of  the  cornea; 
hence,  convex  lenses,  by  lengthening  d,  increase  the  size 
of  the  retinal  images.  Concave  lenses  put  n  further  back, 
and  by  thus  shortening  d  lessen  the  size  of  the  images.  If 
the  lens,  which  corrects  any  optical  error  of  the  eye,  be 
placed  at  the  "  anterior  focus  "  of  the  eye,1 13  mm.,  or  half 
an  inch  in  front  of  the  cornea,  n  moves  to  its  normal  distance 
(15  mm.)  from  the  retina,  and  the  images  are  therefore  re- 
duced or  enlarged  to  the  same  size  as  in  the  normal  eye. 

The  length  of  the  visual  axis,  a  line  drawn  from  the  yel- 
low spot  to  the  cornea  in  the  direction  of  the  object  looked 
at,  is  about  23  mm.  The  centre  of  rotation  of  the  eye  is 
rather  behind  the  centre  of  this  axis,  and  6  mm.  behind 
the  back  of  the  lens.  It  may  here  be  mentioned  that  the 

1  The  anterior  focus  is  the  point  where  rays,  which  were  parallel 
in  the  vitreous,  are  focussed  in  front  of  the  cornea. 


OPTICAL     OUTLINES.  27 

focal  length  of  the  cornea  is  31  mm.,  and  that  of  the  crys- 
talline lens  from  43  mm.  with  accommodation  relaxed,  to 
33  mm.  during  strong  accommodation. 

The  optical  conditions  of  clear  sight  are  as  follows : 
(1)  The  image  must  be  formed  exactly  on  the  retina 
i.  e.,  the  retina  must  lie  exactly  at  the  focus  of  the  dioptric 
media  for  the  object  looked  at.  (2)  The  image  must  be 
formed  at  the  centre  of  the  yellow  spot  (see  Acuteness  of 
sight).  (3)  The  image  must  have  a  certain  size,  and  this 
is  expressed  by  the  size  of  the  corresponding  visual  angle 
(v,  Fig.  19)  ;  with  average  light  v  must  be  equal  to  at  least 
five  minutes  (^  of  a  degree)  in  order  to  the  perception  of 
the  form  of  the  image ;  an  object  subtending  any  smaller 
angle  (down  to  about  one  minute)  is  still  visible,  though 
only  as  a  point  of  light.  Influence  of  the  pupil. — Other 
things  being  equal,  the  larger  the  pupil  the  worse  is  the 
sight,  the  clearness  of  the  images  being  lessened  by  the 
spherical  aberration  caused  by  the  marginal  part  of  the 
lens.  For  the  same  reason  troublesome  distortion  of  the 
images  is  often  caused  by  the  operation  of  iridectomy. 

Numeration  of  spectacle  lenses. — Some  system  of  num- 
bering is  required  which  shall  indicate  the  refractive  power 
of  the  lenses  used  for  spectacles.  Two  systems  are  current: 
In  the  first  system,  which  was  till  lately  universal,  the 
unit  of  strength  was  a  lens  of  1"  focal  length.  As  all  the 
lenses  used  are  weaker  than  this,  their  relative  strengths 
can  be  expressed  only  by  using  fractions.  Thus,  a  lens  of 
2"  focus  is  half  as  strong  as  the  unit,  and  is,  therefore,  ex- 
pressed as  ^;  a  lens  of  10"  focus  is  ^;  of  20"  focus  •£$; 
and  so  on.  The  inconvenience  of  using  fractions  in  prac- 
tice is  considerable,  and,  moreover,  the  intervals  between 
the  successive  numbers  are  very  unequal.  Then  the  length 
of  the  inch  is  not  the  same  in  all  countries,  so  that  a  glass 
of  the  same  number  has  a  somewhat  different  focal  length 
according  as  it  is  made  by  the  Paris,  English,  or  German 


28  OPTICAL     OUTLINES. 

inch.  In  the  second  system,  which  is  fast  displacing  the 
old  one,  the  metrical  scale  is  used ;  the  unit  is  a  weak  lens 
of  1  metre  (100  cm.)  focal  length,  and  known  as  a  dioptre 
(D);  and  the  lenses  differ  by  equal  refractive  intervals. 
A  lens  of  double  the  strength  of  the  unit,  or  half  a  metre 
(50  cm.)  focal  length,  is  2  dioptres  (2  D),  a  lens  of  ten 
times  the  strength,  or  one-tenth  of  a  metre  focus  (10  cm.), 
is  10  D,  and  so  on.  The  weakest  lenses  are  .25,  .5,  and  .75 
D,  and  intermediate  numbers  differing  by  .5  or  .25  D  are 
also  introduced  between  the  whole  numbers.  A  slight 
inconvenience  of  the  metrical  dioptric  system  is  that  the 
number  of  the  lens  does  not  express  its  focal  length.  But 
this  can  be  obtained  by  dividing  100  by  the  number  of 
the  lens  in  D;  thus  the  focal  length  of  4  D  =  if^  =  25 
cm.  If  it  is  desired  to  convert  one  system  into  the  other, 
this  can  be  done,  provided  that  we  know  what  inch  was 
used  in  making  the  lens  whose  equivalent  is  required  in  D. 
The  metre  is  equal  to  about  37  Paris  and  39  English  or 
German  inches;  a  lens  of  36  Paris  inches  (No.  36  or  ^ 
old  scale),  or  of  40  English  or  German  inches  (No.  40  or 
-fa),  is  very  nearly  the  equivalent  of  1  D.  A  lens  of  6 
Paris  inches  (£  =  ^6g-)  will  therefore  be  equal  to  6  D ;  a 
lens  of  18  Paris  inches  (-fa  =  -fo)  =  2  D,  etc.;  a  lens  of  4 
D  =  -£g  —  -g-,  i.  e.,  a  lens  of  9  Paris  inches,  etc. 

The  following  lenses  are  used  for  spectacles,  and  are, 
therefore,  necessary  in  a  complete  set  of  trial  glasses.  The 
first  column  gives  the  number  in  D,  the  second  the  focal 
length  in  metres,  the  third  the  approximate  numbers  on 
the  Paris  inch  scale,  the  denominator  of  each  fraction 
showing  the  focal  length  in  Paris  inches.  In  some  cases 
there  are  no  equivalent  lenses  made  on  the  inch  system. 
In  this  table,  and  throughout  the  work,  convex  lenses  are 
indicated,  according  to  custom,  by  the  -(-  sign;  concave 
lenses  by  the  —  sign. 


OPTICAL     PRINCIPLES. 


29 


1. 

2. 

3. 

1. 

2. 

3. 

No.  in  D. 

Focal 

No.  and  Fo- 

No. in  D. 

Focal 

No.  and  Fo- 

+ (convex) 
or 

Length  in 
cm. 

cal  Length  in 
Paris  inches. 

-+•  (convex) 
or 

Length  in 
cm. 

cal  Length  in 
Paris  inches. 

—  (concave). 

—  (concave). 

0.25 

4.00 

5. 

0.20 

J 

0.5 

2.00 

T2 

5.5 

0.18 

0.75 

1.33 

"sV 

6. 

0.16 

i 

1. 

1.00 

1 
"ST 

7. 

0.14 

k 

1.25 

0.80           A 

8. 

0.125 

1.5 

0.66 

ih 

9. 

0.111 

i* 

1.75 

0.57 

10. 

0.10 

*« 

2. 

0.50 

Y 

TS 

11. 

0.09 

2.25 

0.44 

12. 

0.083 

i 

2.5 

0.40 

T? 

13. 

0.077 

2.75 

0.36 

TV 

14. 

0.07 

}N 

3. 

0.33 

TV 

15. 

0.067 

JM 

3.5 

0.28 

16. 

0.062 

J., 

4. 

0.25 

18. 

0.055 

I 

4.5 

0.22 

I 

¥ 

20. 

0.05 

3* 


30      EXTERNAL    EXAMINATION    OF    THE    EYE. 


CHAPTER    II. 

EXTERNAL  EXAMINATION  OF  THE  EYE. 

(1)  To   detect  irregularity  of   the  corneal  surface : 
whilst  the  patient  follows  with  his  eyes  some  object,  e.  g.,  the 
uplifted  finger,  moved  slowly  in  different  directions,  watch 
the  reflection  of  the  window  from  the  cornea ;  it  will  be 
suddenly  broken  by  any  irregularity,  such  as  an  abrasion 
or  ulcer. 

(2)  To  estimate  the  tension  of  the  eyeball  (T.) :  the 
patient  looks  steadily  down,  and  gently  closes  the  eyelids ; 
the  observer  then  makes  light  alternate  pressure  on  the 
globe  through  the  upper  lid  with  one  finger  of  each  hand, 
as  in  trying  for  fluctuation,  but  much  more  delicately.    The 
finger-tips  are  placed  very  near  together,  and  as  far  back 
over  the  sclerotic  as  possible.    The  pressure  must  be  gentle 
and  be  directed  vertically  dmvnwards,  not  backwards.     It  is 
best  for  each  observer  to  keep  to  one  pair  of  fingers,  not  to 
use  the  index  at  one  time  and  the  middle  finger  at  another. 
Patient  and  observer  should  always  be  in  the  same  relative 
position,  and  it  is  best  for  both  to  stand  and  face  one 
another.     Always  compare  the  tension  of  the  two  eyes. 
Be  sure  that  the  eye  does  not  roll  upwards  during  exami- 
nation, for  if  this  occur  a  wrong  estimate  of  the  tension 
may  be  formed.     Some  test  both  eyes  at  once  with  two  fin- 
gers of  each  hand.     Normal  tension  is  expressed  by  T.  n. 
The  degrees  of  increase  and  decrease  are  indicated  by  the 
-(-or  —  sign,  followed  by  the  figure  1,  2,  or  3.     Thus 
T.  -f-  1  means  decided  increase  ;  T.  -f-  2,  greater  increase, 
but  sclerotic  can  still  be  indented ;  T.  -f-  3,  eye  very  hard, 


EXTERNAL  EXAMINATION  OF  THE  EYE.   31 

cannot  be  indented  by  moderate  pressure ;  T.  —  1, —  2,  —  3, 
indicate  successive  degrees  of  lowered  tension.     A  note  of 
interrogation  (T.  ?  -f-  or  ?  — )  for  doubtful  cases,  and  T.  n. 
for  the  normal,  give  nine  degrees,  which  may  be  usefully 
distinguished.     Equally  good  observers  often  differ  in  re- 
gard to  the  minor  changes  of  tension.     Apart  from  varia- 
tions in  delicacy  of  touch,  it  is  to  be  remembered  that  eyes 
deeply  set  in  the  orbits  are  more  difficult  to  test,  and  that 
T.  in  a  few  cases  really  does  change  at  short  intervals,  e.  g.t 
within  half  an  hour.     Increased  rigidity  of  the  sclerotic, 
which  occurs  naturally  in  old  age  and  sometimes  from  dis- 
ease, alters  the  apparent  tension,  though  the  internal  pres- 
sure may  be  normal  or  even  too  low.     When  a  blind  eye 
contains  bone,  it  feels  like  wood  covered  with  washleather. 
(3)   The  mobility  of  the  eyeball  may  be  impaired  in 
any  or  every  direction,  and  in  any  degree  up  to  absolute 
fixity.     Commonly  only  one  eye  is  affected.     First  direct 
the  patient  with  both  eyes  open  to  look  strongly,  or  follow 
some  upheld  object  moved  in  each  of  the  four  cardinal 
directions  (up,  down,  right,  left)  ;  and  next  to  look  at  an 
object  (finger  or  pencil)  held  vertically  in  the  middle  line, 
rather  below  the   horizontal,  and  gradually  approached 
from  2'  to  about  6",  to  test  the  convergence  power.     In 
each  position  we  must  notice  both  eyes ;  thus,  when  the 
patient  looks  to  his  right  we  have  to  note  the  outward 
movement  of  his  right  and  the  inward  movement  of  his  left. 
The  fixed  marks  for  the  inward  and  outward  movements 
are  the  inner  and  outer  cauthi,  and  as  the  apparent  range 
of  movement  judged  in  this  way  varies  a  little  in  different 
people,  the  corresponding  movements  of  the  two  eyes  should 
always  be  compared.     In  looking  strongly  outwards,  the 
corneal  margin  often  does  not  quite  reach  the  outer  can- 
thus,  but  always  fully  reaches  the  inner  canthus  during  in- 
ward rotation.     In  children  and  stupid  people  the  move- 
ments are  often  defective  from  inattention  rather  than  want 


32   EXTERNAL  EXAMINATION  OF  THE  EYE. 

of  power.  In  very  myopic  eyes  the  movements  are  some- 
what defective  in  all  directions.  Upward  movement  may 
be  estimated  by  noting  the  position  of  the  cornea  in  rela- 
tion to  the  border  of  the  lower  lid ;  the  border  of  the  upper 
lid  is  less  trustworthy,  since  there  may  be  some  ptosis  or 
other  cause  of  inequality  between  the  two  sides. 

(4)  Squint  or  strabismus  exists  if  the  visual  axes  are 
not  both  directed  to  the  same  object.  A  squint  may  be  the 
result  either  of  overactiou  or  of  weakness  or  paralysis  of  a 
muscle:  the  internal  rectus  by  excessive  contraction  often 
causes  convergent  squint ;  most  other  forms,  as  well  as  some 
convergent  cases,  result  from  actual  defect  of  nervous  or 
muscular  power. 

When  a  squint  is  well  marked  there  is  no  difficulty  in 
identifying  the  squinting  eye  as  the  one  which  is  not  di- 
rected towards  an  object  held  up  to  the  patient's  attention: 
in  most  cases  the  patient  always  squints  with  the  same  eye, 
but  in  a  few  he  will  squint  with  either  indifferently  (alter- 
nating squint).  Nor  is  there  often  any  doubt  as  to  whether 
the  squint  is  internal  (convergent)  or  external  (divergent), 
i.  e.,  whether  the  axis  of  the  squinting  eye  crosses  that  of 
its  fellow  between  the  patient  and  the  object  he  looks  at,  or 
crosses  it  beyond  this  object,  or  even  positively  diverges 
from  it ;  upward  or  downward  squint,  though  less  common, 
is  almost  as  evident.  But  to  prove  beyond  doubt  which  is 
the  squinting  eye,  direct  the  patient  to  look  at  a  pencil  held 
up  in  the  middle  line  at  about  18"  from  his  face,  and  with 
a  card  or  piece  of  ground  glass  cover  the  apparently  sound, 
or  "working"  eye;  the  squinting  eye  will  at  once  move  so 
as  to  look  at  or  "fix"  the  pencil,  proving  that  it  had  pre- 
viously been  misdirected.  If  the  sound  eye  be  watched 
behind  the  screen  it  will  be  seen  to  squint  as  soon  as  the 
affected  eye  "fixes"  the  object;  this  is  known  as  the 
secondary  squint,  and  its  direction  is  the  same  as  that  of  the 
original  or  primary  squint.  Thus,  if  the  primary  squint  is 


EXTERNAL  EXAMINATION  OF  THE  EYE.   33 

convergent,  the  secondary  will  also  be  convergent.  In 
squint  from  overaction  or  from  mere  disuse  of  one  muscle, 
the  secondary  and  primary  deviations  are  equal,  but  in 
paralytic  squint  the  secondary  often  exceeds  the  primary. 
The  term  concomitant  is  used  for  any  case  in  which  the 
squinting  eye  has  full  range  of  movement,  i.  e.,  moves  in 
companionship  with  its  fellow  in  all  directions,  and  it  is 
complementary  to  paralytic;  hence,  in  every  case  of  squint, 
it  is  necessary  to  test  the  mobility  of  the  eyes.  It  is  also 
important  to  note  whether  the  squint  is  constant  or  only 
occasional  (periodic.')1 

(5)  Diplopia  (double  sight)  is  almost  always  a  result  of 
squint,  but  the  most  troublesome  diplopia  is  often  caused 
by  a  deviation  too  slight  to  be  perceptible.  Diplopia  is 
almost  always  binocular,  disappearing  when  one  eye  is 
covered.  Uniocular  diplopia  (double  sight  with  one  eye), 
however,  occurs  in  commencing  cataract,  and  is  occasion- 
ally seen  in  cases  of  cerebral  tumor.  In  the  former  it  has 
a  physical  cause  in  the  crystalline  lens;  in  the  latter  it 
must  depend  upon  some  cerebral  change,  and  its  existence 
should  be  accepted  with  great  caution. 

To  find  out  what  defect  of  movement  is  causing  binocu- 
lar diplopia,  take  the  patient  into  a  dark-room,  and,  stand- 
ing at  a  distance  of  6'-8',  ask  him  to  follow  with  his  eyes 

1  It  is  necessary  to  be  aware  that  an  apparent  squint,  either  ex- 
ternal or  internal,  is  sometimes  met  with.  The  optic  axis  of  the 
ej'e  passes  from  a  point  rather  to  the  inner  side  of  the  y.  s.  through 
the  centre  of  the  cornea,  and  forms  a  small  angle  ("angle  a") 
with  the  visual  axis,  which  joins  the  y.  s.  with  the  object  looked 
at  and  commonly  cuts  the  cornea  rather  within  its  centre.  As  we 
judge  of  the  apparent  direction  of  a  person's  eyes  by  the  centres 
of  his  cornese  (i.  e.)  by  the  optic  axes),  a  slight  apparent  outward 
squint  will  be  produced  if  the  angle  a  be  (as  in  many  hyperme- 
tropic  eyes)  larger  than  usual,  and  an  apparent  convergent  squint 
if,  as  in  myopia,  it  be  smaller.  Apparent  squint  is  always  slight, 
and  the  screen  test  described  in  the  text  gives  a  negative  result. 


34   EXTERNAL  EXAMINATION  OF  THE  EYE. 

a  candle  moved  successively  into  different  positions,  and  to 
describe  the  relative  places  of  the  double  images  in  each 
position.  Ascertain  which  of  the  two  images  belongs  to 
each  eye  by  placing  before  one  eye  a  strongly  colored  glass, 
or  by  covering  one  eye  and  asking  which  image  disappears. 
In  many  cases  the  image  formed  in  the  squinting  eye  (the 
"false"  image)  is  less  bright  or  distinct,  and  this  difference 
gives  a  valuable  means  of  distinguishing  the  sound  from 
the  affected  eye ;  but  the  patient  does  not  always  notice 
such  a  difference  between  the  two  images,  and  it  may  then 
be  difficult  to  be  sure  which  eye  is  at  fault.  The  patient's 
replies  should  be  recorded  on  a  diagram  (see  Chapter 
XXI.) ;  the  radii  there  shown  may  of  course  be  increased 
for  intermediate  positions.  The  false  image  is  marked  by 
the  dotted  line,  the  true  one  by  the  unbroken  line.  We 
have  thus  a  graphic  representation  of  the  candle  as  it  ap- 
pears to  the  patient,  and  can  deduce  from  the  apparent 
position  of  the  false  image  what  movements  of  the  corre- 
sponding eye  are  at  fault,  and,  consequently,  which  muscle 
or  muscles  are  defective.  It  is  essential  that  the  patient 
should  not  move  his  head  during  the  examination,  and  that 
he  remain  throughout  at  the  same  distance  from  the  candle. 
Remember  that,  in  the  extreme  lateral  movements,  the 
nose  interferes,  and  eclipses  one  image.  When  the  double 
images  are  very  wide  apart,  the  patient  sometimes  fails  to 
notice  the  false  image. 

For  the  diagnosis  of  a  case  of  diplopia  it  is  often  sufficient 
to  ask  in  which  directions  the  double  sight  is  most  trouble- 
some, and  how  the  images  appear  in  respect  to  height, 
lateral  separation,  and  apparent  distance  from  the  patient 
(see  Chapter  XXI). 

(6)  Protrusion  (proptosis)  and  enlargement  of  the  eye. 
— Unequal  prominence  of  the  two  eyes  is  best  ascertained 
by  seating  the  patient  in  a  chair,  standing  behind  him, 
and  comparing  the  summits  of  the  two  cornese  with  each 


EXTERNAL  EXAMINATION  OF  THE  EYE.   35 

other,  and  Avith  the  bridge  of  the  nose,  or  the  line  of  the 
eyebrows.  The  appearance  of  prominence  or  recession,  as 
seen  from  the  front,  depends  very  much  on  the  quantity  of 
sclerotic  exposed  ;  thus,  slight  ptosis  gives  a  sunken  appear- 
ance to  the  eyes,  and  in  slight  cases  of  Graves'  disease  the 
proptosis  seems  to  increase  when  the  upper  lids  are  spas- 
modically raised.  It  is  to  be  remembered  that  real  promi- 
nence of  the  eye  may  depend  on  enlargement  of  the  eyeball 
(myopia,  staphyloma,  intra-ocular  tumor),  as  well  as  on  its 
protrusion,  and  that  if  only  one  eye  be  myopic,  the  appear- 
ance will  be  unsymmetrical.  Decided  proptosis  may  follow 
tenotomy  or  paralysis  of  one  or  more  orbital  muscles.  In 
hypermetropia,  in  which  the  eyeball  is  too  short,  and  in 
the  rare  cases  of  paralysis  of  the  cervical  sympathetic,  the 
eye  often  looks  sunken. 

(7)  Information  derived  from  the  bloodvessels  visible 
on  the  surface  of  the  eyeball. — Three  systems  of  vessels 
have  to  be  considered  in  disease;  all,  however,  owing  to 
their  small  size,  are  but  imperfectly  visible  in  health.  (1) 
The  vessels  proper  to  the  conjunctiva  (posterior  conjunctival 
vessels"),  in  which  it  is  not  important  to  distinguish  between 
arteries  and  veins  (Fig.  20,  Post.  Cory'.,  and  Fig.  21).  (2) 
The  anterior  ciliary  vessels,  lying  in  the  subconjunctival 
tissue,  and  which,  by  their  perforating  branches,  supply  the 
sclerotic,  iris,  and  ciliary  body,  and  receive  blood  from 
Schlemm's  canal  and  the  ciliary  body;  the  perforating 
branches  of  the  arteries  (Fig.  20,  A)  are  seen  in  health  as 
several  rather  large  tortuous  vessels,  which  stop  short  about 
Ty  or  -|"  from  the  corneal  margin  (Fig.  22) ;  their  epi- 
scleral  non-perforating  branches  are  very  small  and  numer- 
ous, invisible  in  health,  but  when  distended  forming  a  pink 
zone  of  fine,  nearly  straight,  very  closely-set  vessels  round 
the  cornea  (Fig.  20,  A,  and  Fig.  23)  ("  ciliary  congestion," 
"  circum-corneal  zone,"  see  Iritis  and  Diseases  of  Cornea) ; 
the  perforating  veins  are  very  small,  but  more  numerous 


36      EXTERNAL   EXAMINATION    OF   THE   EYE. 

than  the  perforating  arteries  (Fig.  20,  v),  and  their  episcleral 
twigs  form  a  closely-meshed  network  (Fig.  24).  (3)  The 
vessels  proper  to  the  margin  of  the  cornea  and  immediately 

FIG.  20. 


Pcstting 


Vessels  of  the  front  of  the  eyeball,  c.  m.  Ciliary  muscle.  Ch.  Choroid. 
Scl.  Sclerotic.  V.  V.  Vena  vorticosa.  /.  Marginal  loop-plexus  of  cornea. 
Ant.  and  Post.  Conj.  Anterior  and  posterior  conjunctival  vessels.  Ant. 
Oil.  A.  and  V.  Anterior  ciliary  arteries  and  veins.  (Simplified  and  al- 
tered from  Leber.) 

adjacent  zone  of  conjunctiva  (anterior  conjunctival  vessels, 
and  their  loop-plexus  on  the  corneal  border,  Fig.  20,  /,  and 


EXTERNAL  EXAMINATION  OF  THE  EYE.   37 
Fis.  21. 


Conjunctival  congestion  (engorgement  of  the  posterior  conjunctiva! 
arteries  and  veins).     (After  Guthrie.) 

FIG.  22. 


The  perforating  branches  of  the  anterior  ciliary  arteries.  The  dusky 
spots  at  the  seats  of  perforation  are  often  seen  in  dark-complexioned  per- 
sons. (Dalrymple). 

FIG.  23.  FIG.  24. 


"Ciliary  congestion"  (engorge- 
ment of  episcleral  twigs  of  anterior 
ciliary  arteries).  (After  Dalrymple.) 


Congestion  of  anterior  ciliary 
veins  (episcleral  venous  plexus).' 
(After  Dalrymple.) 


38      EXTERNAL    EXAMINATION    OF   THE    EYE. 

Fig.  46)  ;  by  these  numerous  minute  branches,  which  are 
offshoots  of  the  anterior  ciliary  vessels,  Systems  1  and  2 
anastomose. 

Speaking  generally,  congestion  composed  of  tortuous, 
bright  (brick-red)  vessels  (System  1)  moving  with  the  con- 
junctiva when  it  is  slid  over  the  globe,  and  which  is  least 
intense  just  around  the  cornea  (Fig.  21),  indicates  a  pure 
conjunctivitis  (ophthalmia),  and  will  usually  be  accompa- 
nied by  muco-purulent  or  purulent  discharge.  (2)  A  zone 
of  pink  congestion  surrounding  the  cornea,  and  formed  by 
small,  straight,  parallel  vessels,  closely  set,  radiating  from 
the  cornea,  and  not  moving  with  the  conjunctiva  (anterior 
ciliary  arterial  twigs,  Fig.  23),  points  to  irritation  or  in- 
flammation of  the  cornea,  or  iris.  A  more  scanty  zone  of 
dark  or  dusky  color  (Fig.  24),  which,  when  severe,  is  finely 
reticulated  (episcleral  venous  plexus),  often  points  to  glau- 
coma, but  may  accompany  other  diseases,  especially  in  old 
people.  Congestion  in  the  same  region,  more  deeply  seated, 
and  of  a  peculiar  lilac  tint,  especially  if  unequal  in  differ- 
ent parts  of  the  zone,  shows  cyclitis  (anterior  choroiditis). 
(3)  Congestion  in  the  same  zone,  and  also  composed  of 
small  vessels,  but  superficially  placed,  bright  red,  and  often 
encroaching  a  little  on  the  cornea  (anterior  conjunctival  ves- 
sels and  loop-plexus  of  cornea,  Fig.  46),  shows  a  tendency  to 
a  severe  form  of  superficial  corneal  inflammation.  Local- 
ized or  fasciculated  congestion  generally  points  to  phlyc- 
tenular  disease  (Figs.  39  and  40).  Although  in  the  severe 
forms  of  any  acute  disease  of  the  front  of  the  eye  these 
types  of  congestion  are  often  mixed  and  but  imperfectly 
distinguishable,  much  information  may  often  be  derived 
from  attention  to  the  leading  forms  described. 

(8)  Note  the  color  of  the  iris,  and  compare  it  with  that 
of  the  fellow  eye.  In  some  persons  the  irides,  although 
healthy,  are  of  different  colors,  one  blue  or  gray,  the  other 
brown  or  greenish;  and  sometimes  one  iris  shows  large 


EXTERNAL  EXAMINATION  OF  THE  EYE.   39 

patches  of  lighter  or  darker  color  than  its  fellow  (piebald). 
But  if  the  iris  of  an  inflamed  eye  is  greenish  Avhile  its  fellow 
is  blue,  we  should  suspect  iritis ;  and  if  the  iris  of  a  defective 
eye  be  different  from  its  fellow  some  morbid  change  should 
be  suspected. 

(9)  The  pupils  are  to  be  examined  as  to  (1)  equality, 
(2)  size  in  ordinary  light,  (3)  mobility,  (4)  shape.  The 
pupils  are  often  large  and  inactive,  and  sometimes  oval  in 
amaurotic  patients,  in  glaucoma,  and  in  paralysis  of  the 
circular  fibres  of  the  iris  (supplied  by  the  third  nerve). 
They  may  be  too  large  but  still  active  in  myopia  and  in 
conditions  of  defective  nerve-tone.  Wide  dilatation  of  one 
or  both  pupils,  with  dimness  of  sight  of  a  few  days'  dura- 
tion, and  without  ophthalmoscopic  signs  of  disease,  is 
usually  traceable  to  atropine  or  belladonna,  used  by  acci- 
dent or  design,  causing  paralysis  of  accommodation.  When 
very  small,  the  pupil  is  seldom  quite  round. 

The  pupils  in  health  lie  slightly  to  the  inner  side  of  the 
centre  of  the  cornea ;  they  should  be  round,  and,  when 
equally  lighted,  equal  in  size.  When  one  eye  is  shaded  its 
pupil  should  dilate  considerably,  and  on  exposure  contract 
quickly  to  its  former  size  ("  direct  reflex  action ")  :  during 
this  trial  the  other  pupil  will  act,  but  to  a  less  extent  ("  in- 
direct reflex  action"}.  The  pupils  contract  when  the  gaze 
is  directed  to  a  near  object  (say  6"  off),  i.  e.,  during  accom- 
modation and  convergence,  and  dilate  in  looking  at  a  dis- 
tant object;  but  the  range  of  this  "associated  action"  is 
much  less  than  of  the  reflex  action.  The  pupils  may  be 
motionless  to  light  and  shade  from  iritic  adhesions,  or 
from  atrophy  of  the  iris  in  glaucoma  or  other  local  dis- 
ease; and  such  conditions  should  be  carefully  noted  or  ex- 
cluded. Reflex  action  is  lost  when  the  eyes  are  blind  from 
disease  of  optic  nerves  or  retinse ;  if  only  one  eye  be  blind, 
the  direct  action  of  its  pupil  will  be  lost,  but  (unless  there 
be  disease  of  its  third  nerve  also)  the  indirect  action  will 


40   EXTERNAL  EXAMINATION  OF  THE  EYE. 

be  much  greater  than  in  health.  When  one  eye  is  blind 
its  pupil  is  often  rather  larger  than  the  other.  Reflex  action 
may  also  be  lost  without  any  affection  of  sight,  and  without 
loss  of  associated  action  (see  Chapter  XXIII.). 

The  dilatation  effected  by  atropine  is  often  less  in  old 
than  in  young  people.  Marked  inequality  of  pupils  is 
rare,  except  from  disease  or  widely  different  refraction  in 
the  two  eyes.  When  very  active  pupils  are  suddenly  ex- 
posed after  being  shaded,  they  often  oscillate  for  a  few 
seconds  before  settling,  and  finally  remain  a  little  larger 
than  at  the  first  moment  of  exposure.  Considerable  differ- 
ences, both  in  range  and  rapidity  of  action  of  the  pupils,  are 
compatible  with  health;  in  general,  however,  the  pupils 
become  smaller  and  lose  both  in  range  and  rapidity  with 
advancing  years.  Marked  inactivity,  with  small  size,  al- 
ways leads  to  suspicion  of  spinal  or  cerebral  disease.  The 
pupils  are  smaller  whenever  the  iris  is  congested,  whether 
this  be  a  merely  local  condition  (e.  g.,  in  abrasion  of  cor- 
nea), or  form  part  of  a  more  general  congestion,  as  in 
typhus  fever1  and  in  plethoric  states,  or  be  caused  by 
venous  obstruction,  as  in  mitral  regurgitation  and  bron- 
chitis. They  are  large  in  ansemia,  and  in  cases  where  the 
systemic  arteries  are  badly  filled,  such  as  aortic  insuffi- 
ciency,2 and  during  rigors. 

(10)  The  field  of  vision  is  the  entire  surface  from  which, 
at  a  given  distance,  light  reaches  the  retina,3  the  eye  being 

1  The  small  pupil  of  typhus  and  the  frequently  large  pupil  of 
typhoid  are  ascribed  by  Murchison  to  the  differences  in  the  vascu- 
larity  of  the  iris  (as  a  part  of  the  whole  eyeball)  in  the  two  dis- 
eases.    'Continued  Fevers,   541. 

2  See  an  article  on  "  The  Indications  Afforded  by  the  Pupil," 
'Medical  Examiner,'  March  2,  1879. 

8  Strictly  "the  percipient  part  of  the  retina."  It  now  seems 
established  that  the  most  peripheral  zone  of  the  retina  is  not  sen- 
sitive  to  light.  (Landolt.) 


EXTERNAL  EXAMINATION  OF  THE  EYE.   41 

stationary  (Fig.  25).  If  each  part  of  the  field  is  equidistant 
from  the  part  of  the  retina  to  which  it  corresponds,  the  field 
will  form  part  of  a  hemisphere,  with  its  inner  or  concave 
surface  towards  the  eye ;  it  may,  however,  be  projected  on 
to  a  flat  surface,  and  for  many  clinical  purposes  this  is 
quite  accurate  enough.  For  roughly  testing  the  field,  e.  g., 
in  a  case  of  chronic  glaucoma,  or  of  atrophy  of  optic  nerve, 
or  of  hemianopsia,  the  following  is  generally  enough. 
Place  the  patient  with  his  back  to  the  window ;  let  him 

FIG.  25. 


Field  of  vision  with  radius  of  12",  projected  up  to  45°  on  to  a  flat 
surface  two  feet  square.     F,  fixation  spot. 

cover  one  eye,  and  look  steadily  at  the  centre  of  your  face 
or  nose  at  a  distance  of  18"  or  2'.  Then  hold  up  your 
hands  with  the  fingers  spread  out  in  a  plane  with  your 
face,  and  ascertain  the  greatest  distance  from  the  central 
point  at  which  they  are  visible  in  various  directions — up, 
down,  in,  out,  and  diagonally.  It  is  essential  that  the  pa- 
tient should  look  steadily  at  the  face,  and  not  allow  his 
eye  to  wander  after  the  moving  fingers. 

A  more  accurate  method  is  to  make  the  patient  gaze, 
4* 


42   EXTERNAL  EXAMINATION  OF  THE  EYE. 

with  one  eye  closed,  at  a  white  mark  (the  "  fixation  spot") 
on  a  large  black  board  at  a  distance  of  12"  or  18",  and  to 
move  a  piece  of  white  chalk  set  in  a  long  black  handle 
from  various  parts  of  the  periphery  towards  the  fixation 
spot,  until  the  patient  exclaims  that  he  sees  something 
white.  If  a  mark  be  made  on  the  board  at  each  of  about 
eight  such  peripheral  points,  a  line  joining  them  will  give 
with  fair  accuracy  the  boundary  of  the  visual  field  if  it  be 

FIG.  26. 


Field  of  vision  of  right  eye.     w,  boundary  for  white.     B,  for  blue. 
R,  for  red.     G,  for  green.     (Landolt.) 

not  larger  than  45°  in  any  direction;  but  beyond  that 
angle  the  object,  if  on  a  flat  surface,  will  be  much  too  far 
from  the  eye  to  make  the  test  accurate  (see  Fig.  25).  Hence 
a  true  map,  unless  the  field  be  much  contracted,  can  be 


EXTERNAL  EXAMINATION  OF  THE  EYE.   43 

made  only  by  means  of  an  instrument,  the  perimeter,  which 
consists  essentially  of  an  arc  marked  in  degrees,  and  mova- 
ble around  a  central  pivot  on  which  the  patient  fixes  his 
gaze.  The  visual  field  is  not  circular,  but  somewhat  oval, 
with  its  smaller  end  upwards  and  inwards  (Fig.  26).  From 
the  fixation  point  it  extends  90°  or  more  in  the  outward 
direction,  but  only  about  65°  or  rather  less  inwards,  up- 
wards, and  downwards. 

(11)  Testing  the  acuteness  of  sight. — By  acuteness  of 
sight  (V.  or  S.)  is  meant  the  power  of  distinguishing  form, 
and  as  commonly  used  the  term  refers  only  to  the  centre 
of  the  visual  field,  the  peripheral  parts  of  the  retina  having 
a  very  imperfect  power  of  distinguishing  form  and  size. 
V.  varies  considerably  in  different  persons  whose  eyes  are 
normal.  It  is  said  to  diminish  somewhat  in  old  age,  with- 
out disease  of  the  eyes  (Bonders).  The  standard  taken  as 
normal  is  the  power  of  distinguishing  square  letters  that 
subtend  an  angle  of  five  minutes,  the  limbs  of  which  are 
of  uniform  thickness,  each  limb  subtending  an  angle  of  one 
minute  (Snellen's  Test-types).  Rays  forming  so  small  an 
angle  are  very  nearly  parallel,  and  may  be  considered  as 
coming  from  an  object  at  an  infinite  distance.  The  types 
are  made  of  various  sizes,  each  being  numbered  according 
to  the  distance  (in  feet  or  metres),  at  which  it  subtends  a 
visual  angle  of  5  minutes.  Thus,  No.  XX.  subtends  this 
angle  at  20'  (=  No.  6  at  6  m.),  No.  X.  at  10'  (=  No.  3  at 
3  m.),  No.  II.  at  2'  (=  No.  .6  at  .6  m.).  Numerically,  acute- 
ness  of  vision  is  expresed  by  a  fraction,  of  which  the  de- 
nominator is  the  number  of  the  type,  and  the  numerator 
the  greatest  distance  at  which  it  can  be  read;  if  No.  6  is 
read  at  6  m.  V  =  f-  or  1,  i.  e.,  normal;  if  only  No.  18  can 
be  read  at  6  m.  V  =  T6^ ;  if  only  60,  then  V  =  ¥67.  Any 
distance  greater  than  about  3  m.  may  be  selected  for  this 
test,  i.  e.,  No.  3  read  at  3  m.,  or  No.  5  at  5  m.,  generally 
show  the  same  acuteness  as  6  read  at  6  in.  But  at  shorter 


44      EXTERNAL   EXAMINATION    OF   THE   EYE. 

distances  the  accommodation  comes  into  play,  and  the 
illumination  is  often  brighter,  hence  No.  1  at  1  m.  (T)  does 
not  practically  show  the  same  state  of  sight  as  6  at  6  m. 
(£).  It  is,  therefore,  best  to  record  the  fractions  unreduced, 
so  that  the  distance  at  which  the  test  was  used  may  be 
known.  For  testing  near  vision,  Snellen's  types  are 
thought  by  many  to  be  practically  inferior  to  those  of 
Jaeger  and  others,  in  which  the  letters  have  the  form  and 
proportions  found  in  ordinary  type.  (See  Appendix.)  If 
V.  be  very  bad  (less  than  y^),  it  may  be  generally  ex- 
pressed accurately  enough  by  noting  the  distance  at  which 
the  outspread  fingers  can  be  counted  when  exposed  to  a 
good  light  and  against  a  dark  background.  Below  this 
point  we  can  still  distinguish  good  from  bad  or  uncertain 
perception  of  light  and  shade  (jo.  L),  by  alternately  expos- 
ing and  shading  the  eye  with  the  hand  without  touching 
the  face. 

(12)  Accommodation  (A.)  is  tested  clinically  by  meas- 
uring the  nearest  point  (punctum  proximum,  p.~)  at  which 
the  smallest  readable  type  (Snellen's  5  or  Jaeger's  1)  can 
be  clearly  seen.  The  region  of  accommodation  is  the  space 
in  which  it  is  available  (see  Chapter  XX.).  The  ampli- 
tude, power,  or  range  of  A.  is  expressed  in  terms  of  the 
convex  lens,  whose  focal  length  is  =  the  distance  from  the 
cornea  to  p.,  this  being  the  lens  which  adapts  V.  in  an  eye 
without  A.  from  the  farthest  point  of  distinct  vision  (punc- 
tum  remotum,  r.)  to  p. :  thus,  if  p.  be  at  10  cm.  and  A.  be 
subsequently  relaxed,  i.  e.,  the  eye  adapted  for  parallel  rays, 
V.  will  again  be  clear  at  10  cm.  if  a  lens  of  10  cm.  focus 
(  =  10  D.,  see  p.  28)  be  held  close  to  the  cornea ;  because 
rays  from  that  point  will  be  made  parallel  before  entering 
the  eye  (§§  10  and  11). 

The  convergence  of  the  visual  axes  upon  a  point  at  any 
given  distance  is  always  naturally  associated  with  accom- 
modation for  the  same  distance.  The  two  functions  can, 


EXTERNAL  EXAMINATION  OF  THE  EYE.   45 

however,  be  partially  disassociated  to  a  degree  which  varies 
with  age  and  in  different  persons;  i.  e.,  the  accommodation 
can  be  either  relaxed  a  little  or  increased  a  little,  without 
changing  any  given  position  of  the  visual  axes ;  this  inde- 
pendent portion  is  known  as  the  relative  accommodation. 

(13)  The  apparent  size  of  an  object  depends,  in  the  first 
place,  on  the  size  of  its  retinal  image,  and  this,  as  already 
shown  (§  19,  p.  26),  depends  upon  (a)  the  size  of  the  visual 
angle,  and  (6)  the  distance  of  the  retina  from  the  nodal 
point.     It  is  clear  that  in  Fig.  19  a  smaller  object  placed 
nearer  to  the  eye  or  a  larger  one  placed  further  off  might 
subtend  the  same  angle  as  ob,  and  therefore  have  a  retinal 
image  of  the  same  size.     There  are,  however,  other  factors 
contributing  to  our  estimate  of  the  size  of  objects,  especially 
contrast  of  size  and  shade,  estimation  of  distance,  and  effort 
of  accommodation. 

A  white  object  on  a  black  ground  looks  larger  than  a 
black  object  of  the  same  size  on  a  white  ground.  The 
further  off  an  object  is  judged  to  be,  the  larger  does  it 
look.  The  greater  the  accommodative  effort  used,  whatever 
may  be  the  distance  of  the  object,  the  smaller  does  it  ap- 
pear ;  thus,  patients  whose  eyes  are  partly  under  the  in- 
fluence of  atropine,  and  presbyopic  persons  whose  glasses 
are  too  weak,  complain  that  near  objects  if  looked  at  in- 
tently for  a  short  time  get  much  smaller ;  whilst  when  one 
eye  is  under  the  action  of  eserine  (causing  spasm  of  the 
accommodation)  objects  appear  larger  than  if  held  at  the 
same  distance  from  the  other  eye.  Prisms  with  their  bases 
towards  the  temples  seem  to  diminish  objects  seen  through 
them  by  necessitating  excessive  convergence  of  the  eyes. 
(Compare  Fig.  15.) 

(14)  Color  perception  is  best  examined  by  testing  the 
power  of  discriminating  between  various  colors  without 
naming  them.     The  best  test-objects  are  a  series  of  skeins 
of  colored  wool,  or,  for  pocket  use,  smaller  strips  of  colored 


46      EXTERNAL    EXAMINATION   OF   THE   EYE. 

paper,  or  colored  stuffs.  A  color-blind  person  will  expose 
his  defect  by  placing  side  by  side  as  similar,  certain  colors, 
usually  mixed  tints,  which  to  the  normal  eye  appear  quite 
different.  The  set  of  wools  generally  used  was  introduced 
by  Professor  Holmgren,  of  Upsala.1  In  acquired  color- 
blindness (from  atrophy  of  the  optic  nerves),  the  patient, 
if  well  trained  in  colors,  may  be  asked  to  name  them,  and 
his  defect  will  generally  in  this  way  be  correctly  found. 
But  in  congenital  color-blindness  the  confusion  test,  with- 
out naming  the  colors,  is  far  safer;  because,  in  the  first 
place,  such  persons  often  learn  to  distinguish  correctly  be- 
tween many  common-colored  objects  by  differences  of  shade 
(i.  e.,  differences  in  the  quantity  of  white  light  which  they 
reflect,  and  hence  may  escape  detection  unless  tested  with 
a  large  series  of  different  colors,  amongst  which  some,  con- 
taining equal  quantities  of  white,  will  look  exactly  alike ; 
and  secondly,  though  such  persons  often  use  the  names  for 
colors  freely,  the  words  do  not  to  them  convey  the  same 
meaning  as  to  those  with  normal  color-sense,  and  hopeless 
confusion  results  from  an  examination  so  made.  For  de- 
tails, see  Chapters  III.  and  XVI. 

(15)  The  uses  of  prisms  have  been  explained  at  p.  22. 

1  '  De  la  Cecite  des  Couleurs,'  etc.,  1877. 


EXAMINATION    OF  RAILWAY    EMPLOYES.       47 


[CHAPTER    III. 

THE    PRACTICAL    EXAMINATION    OP    RAILWAY    EMPLOYES 

AS    TO   COLOR-BLINDNESS,  ACUTENESS    OF   VISION 

AND  HEARING. 

BY  WILLIAM  THOMSON,  M.D. 

IN  accordance  with  a  wish  expressed  many  months  ago, 
that  I  should  suggest  some  practical  method  for  the  exami- 
nation of  the  employes  of  the  Pennsylvania  Railroad,  as 
to  their  ability  to  see  the  colored  signals  by  day  and  night 
used  in  the  service,  I  devoted  much  time  to  the  subject,  in 
an  effort  to  overcome  the  following  difficulties : 

1.  To  ascertain  whether  each  man  possesses  sight  enough 
to  see  form  at  the  average  distance ;  and  range  of  vision  to 
enable  him  to  see  near  objects  well  enough  to  read  written 
or  printed  orders  and  instructions.  2.  To  learn  if  each 
man  has  color-sense  sufficient  to  judge  promptly,  by  day 
or  night,  between  the  colors  in  use  for  signals.  3.  To  de- 
termine the  ability  of  each  man  to  hear  distinctly. 

The  difficulties  to  be  overcome  were  found  in  the  magni- 
tude of  the  task,  involving  the  examination  of  thousands 
of  men  now  in  the  service,  with  the  necessity  of  extending 
it  to  all  who  may  be  hereafter  employed,  distributed  over 
thousands  of  miles  of  road ;  and  in  the  absence  of  pro- 
fessional experts  in  sufficient  number,  possessing  enough 
special  training  to  fit  them  to  decide  with  precision  the 
points  at  issue. 

It  soon  became  apparent  that  some  system  would  be 
needed  that  could  be  put  in  force  by  each  division  super- 
intendent, acting  through  an  intelligent  employe^  under 
the  general  supervision  of  one  or  more  ophthalmic  sur- 


48      EXAMINATION    OF   RAILWAY   EMPLOYES. 

geons  of  recognized  skill,  to  whom  all  information  collected 
could  be  transmitted,  and  who  would  be  able  to  decide  all 
doubtful  cases,  and  thus  protect  the  road  from  any  danger 
arising  from  incapable  employes,  and  save  good  and  faith- 
ful men  from  the  evil  of  being  discharged  from  the  com- 
pany's service,  or  prevented  from  being  employed  on  other 
roads  on  insufficient  grounds. 

It  was  believed  that  the  facts  could  be  collected  by  non- 
professional  persons,  and  could  be  so  clearly  presented  to 
the  division  superintendent  and  to  the  professional  expert, 
as  to  enable  a  perfectly  correct  decision  to  be  made  in 
every  case ;  and  that  men  fit  for  service  would  be  recog- 
nized, whilst  those  deficient  in  sight,  color-sense,  or  hearing, 
could  be  referred  to  the  expert  if  they  so  desired,  or  trans- 
ferred to  places  in  the  service  where  their  defects,  if  not 
remediable  by  treatment,  could  do  no  harm  either  to  the 
road  or  to  the  public. 

Such  a  system  was  submitted  to  the  general  manager 
of  the  Pennsylvania  Railroad,  and  has  been  perfected 
by  the  labors  of  a  special  committee  of  the  Society  of 
Transportation  Officers  in  conjunction  with  the  writer. 
The  entire  method  has  furthermore  been  submitted  to  a 
practical  experimental  test  extending  over  nearly  two 
thousand  men,  employed  as  conductors,  engineers,  firemen, 
and  brakemen,  and  the  results  have  satisfied  the  committee 
and  myself  that  our  object  has  been  fully  attained,  and 
that  the  system  proposed  may  now  be  put  in  force  with 
confidence  in  its  practical  utility.  As  an  evidence  of  this, 
I  may  cite  two  complete  detailed  reports,  including  1383 
men  in  all.  The  blanks  upon  which  the  original  entries 
were  made  have  all  been  submitted  to  me,  and  they  satisfy 
me  that  the  results  in  the  summary  of  each  of  these  ex- 
cellent reports  may  be  confidently  accepted,  and  thus  we 
have  become  acquainted  with  the  fact  that  there  were  in 
the  service  of  the  Pennsylvania  Railroad,  of  the  1383  men 


EXAMINATION    OF    RAILWAY    EMPLOYES.       49 

examined,  246  men  deficient  in  the  full  acutenessof  vision, 
55  absolutely  color-blind,  and  21  defective  in  hearing. 

In  one  of  the  reports,  an  examination,  not  included  in 
the  instructions  from  the  committee,  was  made  with  colored 
flags  and  colored  lights  by  night,  and  13  men  failed  to  be 
able  to  recognize  them  from  a  total  of  24,  who  were  color- 
blind to  the  test  used  for  its  detection,  but  I  have  little 
doubt  whatever  that  the  eatire  number  of  color-blind,  viz., 
55,  would  also  fail  under  a  carefully  devised  system  of 
tests  by  the  usual  railroad  signals. 

The  entire  number  reported  as  defective  in  color-sense, 
4^  per  cent.,  is  up  to  the  average  as  reported  by  the  best 
authorities  in.  its  percentage ,  but  those  absolutely  color, 
blind,  and  hence  unable  to  distinguish  between  a  soiled 
white  or  gray  and  green,  or  a  green  and  red  flag,  are  fully 
4  per  cent. ;  and  this  proves  that  the  instrument  employed 
in  this  part  of  the  examination  has  met  our  expectations 
fully. 

As  this  was  the  point  about  which  I  had  most  doubt,  a 
word  or  two  of  explanation  may  be  proper,  more  especially 
as  many  good  authorities  declare  that  no  examination  for 
color-blindness  should  be  accepted,  unless  made  by  pro- 
fessional specialists. 

The  examination  for  color-blindness  now  generally  ac- 
cepted and  proposed  by  Prof.  Holmgren,  consists  in  testing 
the  power  of  a  person  to  match  various  colors,  which  are  most 
conveniently  used  in  the  form  of  colored  yarns.  Usually 
about  150  tints  are  employed,  in  a  confused  mixture,  and 
three  test  colors,  viz.,  light-green,  rose  or  purple,  and  red, 
are  placed  in  the  foregoing  order  before  the  person  ex- 
amined, who  is  directed  to  select  similar  colors  from  the 
mass.  The  examiner  sits  then  in  judgment,  and  decides 
whether  the  color-sense  is  perfect  from  the  selections  made, 
or  from  those  not  made,  or  from  them  both,  and  from  the 
prompt  or  hesitating  manner  of  the  examined.  It  has 

5 


50      EXAMINATION   OF   RAILWAY    EMPLOYES. 

been  our  effort  to  render  this  more  simple,  and  to  so  ar- 
range the  colors  that  they  may  be  identified  by  some  num- 
ber, so  that  an  expert,  although  absent  from  the  scene, 
would  know  by  these  numbers  the  exact  tints  selected,  and 
thus  be  fully  competent  to  declare  from  them  the  color- 
perception  of  any  person  whose  record  had  been  properly 
made.  From  theory  based  upon  scientific  knowledge,  and 
from  much  experience,  I  was  9,ble  to  arrange  an  instru- 
ment that  would  have  the  real  colors,  and  those  usually 
confounded  with  them,  "  confusion  colors,"  placed  in  such 
relations  to  each  other,  and  so  designated  by  numbers,  as  to 
make  an  examination  for  color-blindness  possible  by  a  non- 
professional  person,  who  could  conduct  the  testing,  record 
it  properly,  and  transmit  it  to  an  expert  capable  of  decid- 
ing upon  the  written  results.  Hence  there  is  no  departure 
from  the  system  of  matching  tints  already  established,  the 
only  novelty  being  in  reducing  the  number  of  colors  to 
those  similar  to  the  test  colors,  and  to  those  usually  chosen 
by  color-blind  persons,  and  so  identifying  them  as  to  enable 
an  absent  expert  or  superintendent  to  know  precisely  what 
colors  had  been  selected  to  match  the  test  colors. 

The  theory  of  the  instrument  (consisting  of  a  stick  with 
the  yarns  attached,  see  Fig.  27),  is  that  color-blindness  is 
most  promptly  detected  by  using  the  light-green  test-skein, 
and  asking  that  it  be  matched  in  color  from  the  yarns  on 
the  stick,  which  are  arranged  to  be  alternately  green  and 
confusion  colors,  and  are  numbered  from  one  to  twenty,  the 
person  being  directed  to  select  ten  tints,  and  the  examiner 
being  required  to  note  the  numbers  of  the  tints  chosen.  It 
will  be  understood  that  the  odd  numbers  are  the  green,  and 
the  even  ones  the  confusion  colors,  and  that,  if  a  person  has 
a  good  color-sense,  his  record  will  exhibit  none  but  odd  num- 
bers ;  whilst,  if  he  be  color-blind,  the  mingling  of  even  num- 
bers betrays  his  defect  at  a  glance  to  the  supervising  expert 
or  superintendent. 


EXAMINATION    OF    RAILWAY    EMPLOYES.       51 


52      EXAMINATION    OF    RAILWAY   EMPLOYES. 

There  are  forty  tints  on  the  stick,  and  the  first  twenty 
are  given  to  the  detection  of  color-blindness,  using  the 
green-test,  and  if  the  color-sense  is  deficient,  it  will  surely 
be  revealed. 

To  distinguish,  however,  between  green-blindness  and 
red-blindness,  the  rose-test  is  used,  and  those  color-blind  will 
select  indifferently,  either  the  blues  intermingled  with  the 
rose,  between  figures  20  and  30,  or  perhaps  the  blue-green 
or  grays  from  1  to  20,  and  thus  reveal  their  defect,  and  es- 
tablish either  green-  or  red-blindness. 

Finally,  the  red-test  corroborates  these  results,  and  satis- 
fies the  most  sceptical  of  color  defect,  when  the  "  confusion 
tints  "  or  even  numbers  between  30  and  40  are  selected. 

On  a  suitable  blank  these  figures  are  placed  in  the  order 
of  examination,  and  a  glance  of  the  eye  reveals  the  color- 
sense  of  the  person  examined;  since,  if  anything  but  odd 
numbers  are  chosen,  there  is  a  defect ;  or  if,  with  test  one, 
anything  beyond  20  is  chosen ;  or  if,  with  test  two,  any- 
thing but  odd  numbers  between  20  and  30 ;  or,  with  test 
three,  anything  but  odd  numbers  between  30  and  40.  The 
colors  can  readily  be  changed  on  the  instrument,  if  it  should 
be  found  desirable. 

It  is  theoretically  and  practically  a  fact,  that  the  tints  as 
arranged  in  the  three  sets  on  the  instrument  look  quite  the 
same  in  color  to  color-blind  persons,  and  that  those  having 
a  perfect  color-sense  can  thus  form  an  idea  of  this  infirmity. 
If,  then,  green  and  gray  are  indistinguishable,  and  green  and 
red,  when  of  the  same  depth  of  color,  seem  to  be  entirely  the 
same  to  the  color-blind,  it  needs  no  opinion  from  a  scien- 
tific expert  to  convince  the  manager  of  a  railroad  that  it 
would  be  most  dangerous  to  place  the  lives  of  people  under 
the  guidance  of  an  engineer  who  could  not  distinguish,  if 
green-blind,  between  a  soiled  white  and  a  green  flag,  or  be- 
tween a  green  and  red  flag,  or  other  signal  of  these  colors. 

It  is  a  fact  that  some  of  the  color-blind  promptly  give 


EXAMINATION    OF    RAILWAY    EMPLOYES.       53 

the  proper  names  to  the  flags,  and  answer  correctly,  when 
asked  what  they  would  do  in  presence  of  such  signals,  but 
it  must  be  remembered  that  they  may  see  form  perfectly, 
and  have  always  had  some  perception  of  these  colors,  and  do 
give  them  their  conventional  names,  perhaps,  but  that  they 
are  unable  to  distinguish  them  at  once  and  infallibly,  and 
that  it  will  only  require  a  further  extension  of  our  method 
of  testing  to  demonstrate  the  inability  of  persons  color- 
blind to  our  examination  to  recognize  the  signals,  by  day 
or  night,  which  are  now  depended  upon  to  prevent  acci- 
dents of  the  gravest  character.  This  must  be  done  by  de- 
manding that  the  signals  be  matched,  and  not  named,  and 
this  is  incorporated  in  the  instructions  herewith  submitted, 
so  that  the  tints  which  color-blind  men  select  with  the  rail- 
road signals  from  the  instrument  may  hereafter  be  known 
and  recorded. 

My  conclusions  from  a  study  of  the  subject  in  connection 
with  the  railway  service  are  : 

1.  That  there  are  many  employes  who  have  defective 
sight,  caused  either  by  optical  defects,  which  are,  perhaps, 
congenital,  and  which  might   be  corrected   with   proper 
glasses,  or  due  to  the  results  of  injuries  or  diseases  of  the 
eyes,  remediable  or  not,  by  medical  or  surgical  treatment. 

2.  That  one  man  in  twenty-five  will  be  found  color-blind 
to  a  degree  to  render  him  unfit  for  service  where  prompt 
recognition  of  signals  is  needed,  inasmuch  as  color-blindness 
for  red  and  green  renders  signals  of  these  colors  indistin- 
guishable.     It  is  a  fact  in  physiological  optics,  however, 
that  yellow  and  blue  are  seen  by  those  color-blind  for  red 
and  green,  and  that  yellow-violet  blindness  is  so  rare  that 
it  might  lead  to  the  use  of  these  yellow  and  blue  colors,  in 
preference  to  red  and  green,  wherever  possible. 

3.  That  color-blindness,  although  mainly  congenital  and 
incurable,  is  sometimes  caused  by  disease  or  injury,  and 
that  precautions  might  be  needed  to  have  either  periodical 


54      EXAMINATION    OF    RAILWAY    EMPLOYES. 

examinations  or  to  insist  upon  it  in  cases  where  men  have 
suffered  from  severe  illness  or  injury,  or  -when  they  have 
been  addicted  to  the  abuse  of  tobacco  or  alcohol. 

4.  That  the  method,   when   adopted,   will   enable   the 
authorities  to  know  exactly  how  many  of  their  employes 
are  "satisfactory  in  every  particular"  as  to  sight  and  hear- 
ing; and  that  the  examination  will  have  the  further  value 
of  making  the  division  superintendents  acquainted   with 
the  general  aptitude  of  the  men  in  their  divisions  as  to  gen- 
eral intelligence. 

5.  That  the  entire  examinations  can  be  made  at  the  rate 
of  at  least  six  men  an  hour;   whilst  that  for  color-sense 
alone  can  be  done  in  a  very  few  minutes  for  each  man  by 
an  intelligent  employe. 

6.  That  to  secure  the  confidence  of  the  employes,  and  of 
competent  scientific  critics,  as  well  as  of  the  public  gener- 
ally,  it   is   advisable   to   have   some   official   professional 
specialist  to  whom  all  doubtful  questions  could  be  referred, 
and  who  should  be  held  responsible  for  the  accuracy  of  the 
instruments,  test-cards,  etc.,  to  be  put  in  use,  and  who  should 
have  a  general  supervision  of  the  entire  subject  of  sight, 
color-sense,  and  hearing. 

7.  That  from  the  impossibility  of  subjecting  the  immense 
number  of  employes  on  our  large  railways  to  the  inspection 
of  the  few  medical  experts  available,  and  to  secure  the  ex- 
amination of  those  hereafter  to  be  employed,  some  system 
of  testing  by  the  railway  superintendents  has  become  a 
necessity,  and  it  is  believed  that  the  one  proposed  will  an- 
swer the  purpose. 


EXAMINATION    OF   RAILWAY    EMPLOYES.       55 


PENNSYLVANIA  RAILROAD  COMPANY'S  INSTRUCTIONS  FOR 
EXAMINATION  OF  EMPLOYES  AS  TO  VISION,  COLOR- 
BLINDNESS, AND  HEARING. 

Instructions  for  examination  as  to  vision,  color-blind- 
ness, and  hearing. — The  examination  will  be  made  as  to 
vision,  color-sense,  and  hearing,  and  the  following  appa- 
ratus will  be  used: 

1.  A  card  or  disk  of  large  letters  for  testing  distant 
sight.  2.  A  book  or  card  of  print  for  testing  sight  at  a 
short  distance.  3.  An  adjustable  frame  for  supporting  the 
print  to  be  read,  with  a  graduated  rod  attached  for  meas- 
uring the  distance  from  the  eye  while  reading.  4.  A  spec- 
tacle frame  for  obstructing  the  vision  of  either  eye  while 
testing  the  other.  5.  An  assortment  of  colored  yarns  for 
testing  the  sense  of  color.  6.  A  watch  with  a  loud  tick  for 
testing  the  hearing.  7.  A  book  or  set  of  blanks  for  record- 
ing the  observations.  8.  A  copy  of  an  approved  work  on 
"  Color-blindness." 

Acuteness  of  vision. — For  distant  vision,  place  the  test- 
disk  or  card  in  a  good  light  twenty  feet  distant,  and  ascer- 
tain for  each  eye  separately  the  smallest  letters  that  can 
be  read  distinctly,  and  record  the  same  by  the  number  of 
that  series  on  the  card. 

Range  of  vision. — For  near  vision,  ascertain  the  least 
number  of  inches  at  which  type  D  =  0.5  or  1  £,  can  be  read 
with  each  eye,  and  record  the  result. 

Field  of  vision. — Let  the  examiner  stand  in  front  of  the 
examined,  at  a  distance  of  three  feet,  and  directing  the  ex- 
amined to  fix  his  eyes  on  the  right  eye  of  the  examiner,  and 
keep  them  so  fixed,  let  the  examiner  extend  his  arm  later- 
ally, and  opening  and  shutting  his  hands,  let  him  by  ques- 
tions satisfy  himself  that  his  hands  are  seen  by  the  examined 


56      EXAMINATION   OF   RAILWAY   EMPLOYES. 

without  changing  the  direction  of  the  eyes ;  recording  the 
result  as  good  or  defective,  as  the  case  may  be. 

Color-sense. — Three  test-skeins — A,  light-green ;  B,  rose ; 
C,  red — will  be  used  with  the  colored  yarns  attached  to 
the  stick ;  of  the  latter  there  are  forty  tints,  numbered  from 
1  to  40,  and  arranged  in  three  sets — a,  b,  and  c — of  which 
the  odd  numbers  correspond  to  the  colors  of  the  test-skeins, 
whilst  the  even  numbers  are  different  or  "  confusion  colors." 

The  first  set  is  to  test  for  color-blindness;  the  second  to 
determine  whether  it  be  red  or  green  blindness,  and  the 
third  to  confirm  the  opinion  formed  from  the  first  or  second 
test. 

Place  the  test-skein  A  at  a  distance  of  not  less  than  three 
feet,  and,  without  naming  the  color,  direct  the  person  ex- 
amined to  name  the  color,  and  to  select  from  the  first 
twenty  tints,  or  set  (a),  of  the  yarns  on  the  stick,  ten  tints 
of  the  same  color  as  skein  A,  stating  that  they  do  not 
match,  but  are  different  shades  of  the  same  color.  Record 
the  number  of  the  tints  so  selected.  Do  the  same  with  skeins 
B  and  C,  using  for  B  the  tints  from  21  to  30,  and  for  C  the 
tints  from  31  to  40.  If  the  odd  numbers  are  selected  read- 
ily, the  examination  may  be  gone  over  very  quickly. 

When  color-blindness  is  detected,  any  one  of  the  even 
numbers  or  "  confusion  colors  "  may  be  used  as  a  test-skein, 
and  the  man  may  be  directed  to  select  similar  tints,  when 
he  will  most  probably  choose  odd  numbers,  which  should 
be  recorded,  stating  the  number  on  the  stick  of  the  "  con- 
fusion color"  used  for  a  test,  and  then  giving  the  numbers 
chosen  to  match  it. 

Then  a  soiled  white  flag  should  be  shown,  and  the  man 
be  directed  to  select  tints  to  match  it,  which  should  be  re- 
corded ;  next  a  green,  and  finally  a  red  flag. 

All  of  the  particulars  are  to  be  recorded  as  the  examina- 
tion proceeds,  not  leaving  it  to  memory.  Use  the  numbers 
in  recording.  The  letters  indicating  the  set  need  not  be 


EXAMINATION    OF   RAILWAY   EMPLOYES.      57 

used.  Note  whether  the  selection  is  prompt  or  hesitating 
by  a  distinct  mark  after  the  proper  word  on  the  blank 
form.  When  deficient  color-sense  is  discovered,  and  varia- 
tions in  the  mode  of  testing  are  made  by  the  examiner  or 
examined,  they  should  be  noted  under  remarks,  or  on  a 
separate  sheet  to  be  referred  to,  if  the  blank  has  not  room 
enough. 

Hearing. — Note  the  number  of  feet  or  inches  distant 
from  each  ear  at  which  a  watch,  having  a  tick  loud 
enough  to  be  heard  at  five  feet,  is  heard  distinctly,  using  a 
watch  without  a  tick,  or  a  stop  watch,  to  detect  any 
supposed  deception;  and  the  number  of  feet  at  which 
ordinary  conversation  is  heard. 

Explanations. — The  test-card  contains  letters,  numbered 
from  20  (xx),  or  D  =  6,  to  200  (cc),  or  D  =  60.  Those 
measuring  three-eighths  of  an  inch,  and  numbered  20  (xx) 
or  D  =  6,  are  such  as  a  good  eye  of  ordinary  power  sees  dis- 
tinctly twenty  feet  or  six  metres  distant.  If  a  man  sees 
distinctly  only  those  marked  C  (or  100),  his  acuteness  of 
vision,  V.,  is  equal  to  T2¥°7  or  %.  If  he  sees  to  XX  (or  20), 
then  V.  is  equal  to  f  $  or  1,  and  his  sight  is  up  to  the  full 
standard.  This  mode  of  statement  indicates  the  relative 
value  of  the  sight  examined,  and  should  be  used  in  the 
records.  If  one  eye  is  -|$  or  1,  and  the  other  not  less  than 
f-g-  or  Y«,  with  or  without  glasses,  the  sight  may  be  con- 
sidered satisfactory. 

The  power  of  discerning  small  objects  at  the  reading 
distance  is  tested  by  the  small  print,  and  good  sight  may 
be  assumed  if  one  eye  can  see  at  twenty  inches  the  matter 
marked  1 2  or  D  =  0.5,  whilst  the  other  distinguishes  not 
less  than  4J  or  D=  1.5.  The  small  print  should  then  be 
brought  to  the  point  of  nearest  vision  for  each  eye,  and  that 
point  mentioned  in  inches.  A  good  eye  should  be  able  to 
read  No.  1 J  at  twenty  inches,  and  have  a  range  of  vision 
up  to  ten  inches. 


58      EXAMINATION    OF   RAILWAY    EMPLOYES. 

The  color-test  will  indicate  whether  the  man  is  deficient 
in  color  sense.  The  colors  are  arranged  in  three  sets,  one 
of  20  and  two  of  10  each — the  odd  numbers  are  the  colors 
similar  to  the  test-skeins,  and  the  even,  numbers  are  the 
"  confusion  colors,"  or  those  which  the  color-blind  will  be 
likely  to  select  to  match  the  sample  skeins  or  colors  shown 
him.  The  first  20  (a),  numbered  from  1  to  20,  have  green 
tints  for  the  odd  numbers  or  test-colors.  In  the  second 
(6),  21  to  30,  the  test-colors  are  rose  or  purple,  a  combina- 
tion of  red  and  blue ;  and  in  the  third  (c),  31  to  40,  they  are 
red.  Ordinarily  the  test  will  be  with  each  set  separately, 
but  the  whole  40  may  be  employed  on  any  test-skein.  Any- 
thing but  green  matched  with  green  indicates  a  defect  in 
the  color  sense,  for  which  use  set  (a). 

The  test  with  the  second  set  indicates  whether  red  or 
green  blindness  exists.  The  odd  numbers  from  21  to  30 
are  purple.  If  either  of  these  is  matched  with  test-skein 
B,  nothing  is  indicated,  as  they  must  appear  alike  to  a 
color-blind  person ;  but  if  blue  is  chosen,  red-blindness  is 
indicated,  and  if  green,  then  green-blindness  is  established. 

The  third  set  (c)  is  scarcely  needed,  but  may  be  used  in 
confirmation  of,  or  in  connection  with,  the  last,  as  to  red  or 
green  defect. 

When  the  numbers  of  the  tints  selected  are  recorded  in 
the  proper  blank,  color-blindness  will  be  indicated  in  those 
instances  where  even  numbers  appear,  and  suspicions  will 
arise  where  numbers  beyond  20  are  used  with  test-skein  A, 
and  under  21  or  beyond  30  with  B,  and  below  31  with  C. 

Further  tests  should  be  made  of  those  found  to  be  color- 
blind with  the  usual  signal  flags,  requesting  them  to  name 
each  color,  shown  singly,  and  to  match  the  colors  of  them 
from  the  tints  on  the  stick,  and  with  colored  lamps ;  and 
finally  to  state  what  they  understand  them  to  mean  as 
signals. 

It  will  be  well  not  to  dwell  on  the  examination  of  a  man 


EXAMINATION    OF    IIAILWAY    EMPLOYES.       59 

found  to  be  defective  in  color-sense  or  in  vision,  but  to  pass 
over  each  examination  with  the  same  general  care,  and 
afterwards  send  for  those  giving  indications  of  defects,  to 
come  in  singly  for  fuller  examination.  The  examination 
should  be  private  as  far  as  practicable,  especially  excluding 
persons  who  are  to  be  subsequently  examined. 

Inability  to  name  color  accurately,  or  to  distinguish 
nicely  as  to  difference  in  tint,  is  not  to  be  taken  as  an  evi- 
dence of  color-blindness. 

In  testing  as  to  hearing,  if  the  watch  used  can  be  heard 
at  five  feet  distant,  and  the  person  examined  hears  it  only 
at  one  foot,  his  hearing  would  be  1-5,  and  may  be  so 
recorded  in  fractions.  Conversation  in  an  ordinary  tone 
should  be  heard  at  ten  feet. 

It  should  be  understood  that  all  employes  examined, 
failing  to  come  up  to  the  requirements  of  the  above  stand- 
ard, shall  be  accorded  the  benefit  of  a  professional  ex- 
amination. When  acuteness  of  vision  is  below  the  standard 
adopted,  it  may  be  possible  to  restore  full  vision  by  proper 
glasses,  when  it  is  due  to  optical  defects,  known  as  near- 
sight,  far-sight,  or  astigmatism,  or  by  other  medical  or 
surgical  treatment,  and  useful  men  may  then  be  retained 
in  the  company's  service. 

These  rules  and  regulations,  having  been  approved  by 
the  Board  of  Managers,  have  been  put  into  effect  on  the 
Pennsylvania  Railroad,  under  the  general  supervision  of 
the  writer,  and  give  entire  satisfaction,] 


60  FOCAL    ILLUMINATION. 


CHAPTER   IY. 

EXAMINATION  OF    THE  EYE  BY  ARTIFICIAL   LIGHT. 

THIS  includes  (1)  examination  by  focal  or  oblique  light; 
(2)  examination  by  the  ophthalmoscope. 

(1)  In  using  focal  or  oblique  illumination  the  anterior 
parts  of  the  eye  are  examined  with  the  light  of  a  lamp 
concentrated  by  means  of  a  convex  lens.  It  is  used  for 
the  examination  of  opacities  of  the  cornea,  changes  in  the 
appearance  of  the  iris,  alterations  in  the  outline  and  area 
of  the  pupil  from  iritis,  and  opacities  of  the  lens.  Such  an 
examination  is  to  be  made  by  routine  in  every  case  before 
using  the  ophthalmoscope.  We  require  a  somewhat  dark- 
ened room,  a  convex  lens  of  two  or  three  inches  focal  length 
(one  of  the  large  ophthalmoscope  lenses),  and  a  bright, 
naked  lamp-flame. 

The  patient  is  seated  with  his  face  towards  the  light, 
which  is  at  about  2'  distance.  The  lens,  held  between  the 
finger  and  thumb,  is  used  like  a  burning-glass,  being  placed 
at  about  its  own  focal  length  from  the  patient's  cornea  and 
in  the  line  of  the  light,  so  as  to  throw  a  bright  pencil  of 
light  on  the  front  of  the  eye  at  an  angle  with  the  observer's 
line  of  sight.  Thus  all  the  superficial  media  and  structures 
of  the  eye  can  be  successively  examined  under  strong  illu- 
mination, the  distance  of  the  lens  being  varied  a  little,  ac- 
cording as  its  focus  is  required  to  fall  on  the  cornea,  the  iris, 
or  the  anterior  or  posterior  surface  of  the  crystalline  lens 
(Fig.  28).  By  varying  the  position  of  the  light  and  of  the 
patient's  eye,  making  him  look  up,  down,  and  to  each  side, 
we  can  examine  all  parts  of  the  corneal  surface,  of  the  iris, 


FOCAL    ILLUMINATION. 


61 


FIG.  28. 


of  the  pupillary  area  (i.  e.,  the  anterior  capsule  of  the  lens), 
and  of  the  lens-substance.  If  the  light  be  thrown  at  a  very 
acute  angle  on  the  cornea  or  lens,  opaci- 
ties are  much  more  visible  than  if  it  fall 
almost  perpendicularly. 

For  complete  exploration  of  all  parts 
of  the  crystalline  lens  the  pupil  must  be 
dilated  with  atropine,  but  careful  exam- 
ination without  atropine  will  generally 
enable  us  to  detect  opacities  lying  in  or 
near  the  axis  of  the  lens  even  if  quite 
deeply  seated.     In  examining  the  pos- 
terior pole  of  the  lens  the  light  must  be 
thrown  almost  perpendicularly  into  the 
pupil,  and  the  observer 
must  place  his  eye  as 
nearly  in  the  same  di- 
rection as  is  possible 
without     intercepting 
the     incident     light. 
Opacities  of  the   cor- 
nea and  anterior  lay- 
ers of  the  lens  appear 
whitish;  deep  opacities 
in  the  lens,  especially 

in  old  people,  look  yellowish  by  focal  light.  Tumors  and 
large  opacities  in  the  vitreous,  hemorrhagic  or  other,  may 
be  seen  by  this  method  if  seated  close  behind  the  lens. 
Minute  foreign  bodies  in  the  cornea  will  often  be  seen  by 
focal  light  when  invisible,  because  covered  by  hazy  epithe- 
lium, in  daylight.  By  habitually  magnifying  the  illumin- 
ated parts  by  a  second  lens  held  in  the  other  hand,  much 
additional  information  can  be  gained. 


Focal  illumination. 


62  OPHTHALMOSCOPIC     EXAMINATION. 


(2)  OPHTHALMOSCOPIC  EXAMINATION. 

The  ophthalmoscope  enables  us  to  see  the  parts  of  the 
eye  behind  the  crystalline  lens  by  making  the  observer's 
eye  virtually  the  object  by  which  the  observed  eye  is  lighted 
up.  Rays  of  light  entering  the  pupil  in  a  given  direction 
are  partly  reflected  back  by  the  choroid  and  retina,  and  on 
emerging  from  the  pupil  take  the  same  or  very  nearly  the 
same  course  that  they  had  on  entering  (§  12,  p.  18).  Hence 
the  eye  of  the  observer,  if  so  placed  as  to  receive  these  re- 
turning rays,  must  also  be  so  placed  as  to  cut  off  the  enter- 
ing rays;  as,  therefore,  no  light  can  enter  in  this  direction, 
none  can  return  to  the  observer's  eye.  This  is  why  the  pu- 
pil generally  looks  black.  Although  with  a  large  pupil, 
especially  in  a  hypermetropic  or  myopic  eye,  the  observer 
receives  some  of  the  returning  rays  (because  he  does  not 
intercept  all  the  entering  light),  and  in  this  way  sees  the 
pupil  of  a  fiery  red  instead  of  black,  still  for  any  useful 
examination  the  observer's  eye  must,  as  already  stated,  be 
in  the  central  path  of  the  entering  (and  emerging)  rays. 
This  end  is  gained  by  looking  through  a  small  hole  in  a 
mirror,  by  which  light  is  reflected  into  the  patient's  pupil, 
and  this  perforated  mirror  is  the  ophthalmoscope.  There 
are  two  ways  of  seeing  the  deep  parts  of  the  eyeball  by  its 
means. 

A.  The  indirect  method  of  examination,  by  which  a  clear, 
real,  inverted  image  of  the  fundus,  somewhat  magnified,  is 
formed  in  the  air  between  the  patient  and  the  observer. 

The  following  simple  experiment  will  show  how  this  is 
effected :  Take  two  convex  lenses  of  about  2"  focal  length 
each.  (1)  Hold  one  in  the  left  hand,  at  about  2"  from 
this  print ;  (2)  take  the  second  lens  in  the  right  hand,  and, 
moving  your  head  a  few  inches  back,  hold  the  second  lens 
at  about  its  focal  length  in  front  of  the  first ;  you  will  then 


OPHTHALMOSCOPIC     EXAMINATION.  63 

see  an  inverted  image  of  the  print  slightly  magnified,  a. 
Observe  that  in  order  to  see  this  image  clearly  you  have  to 
make  an  effort,  and  that  you  cannot  see  the  image  and  the 
print  on  the  page  itself,  clearly  at  the  same  moment ;  this 
is  because  the  inverted  image  (im,  Fig.  29 )  lies  in  the  air 
between  the  eye  and  the  second  lens,  and  more  accommo- 
dation is  necessary  for  seeing  it  clearly  than  for  the  object 
(ob}.  The  fundus  of  the  eye  seen  on  this  principle  is  mag- 

FIG.  29. 


<'b  is  the  object,     a.  The   first  lens.     /.  The   second   lens.     im.    The 
magnified  inverted  image  of  ob  viewed  by  the  observer,  obi. 

nified  about  four  diameters,  if  the  eye  be  normal.  The 
image  is  larger  in  H  and  smaller  in  M.  b.  Notice  that  if 
the  observer's  head  be  moved  slightly  from  side  to  side  the 
image  will  appear  to  move  in  the  opposite  direction. 

B.  The  direct  method  of  examination  by  which  (except 
when  the  eye  is  myopic)  a  virtual,  erect  image  is  seen  more 
magnified  than  in  the  former  method  and  behind  the  pa- 
tient's eye. 

The  conditions  are  the  same  as  those  under  which  a 
magnified  image  of  any  object  is  seen  through  a  convex  lens 
(Fig.  12),  as  in  the  following  experiment:  (1)  Hold  a  con- 
vex lens,  of  say  3"  focal  length,  at  any  distance  from  this 


64  OPHTHALMOSCOPIC    EXAMINATION. 

page  not  greater  than  3",  and  place  your  eye  close  to  the 
lens.  The  print  will  be  magnified  and  seen  in  its  true 
position,  i.  e.,  "  erect."  a.  The  enlargement  will  be  more 
the  greater  the  distance  of  the  lens  from  the  page  up  to  3" 
(§§  16  and  17,  p.  19).  If  the  distance  be  further  increased 
the  print  will  not  be  seen  clearly.  The  image  is  a  "  virtual " 
one,  because  it  is  the  image  which  would  be  formed  if  the 
rays  which  enter  the  eye  in  a  diverging  direction  could  be 
prolonged  backwards  until  they  met  behind  the  lens  (Figs. 
12  and  32).  b.  If  the  lens  be  placed  just  at  its  focal  length 
from  the  paper  the  image  will  be  seen  clearly  only  during 
complete  relaxation  of  the  accommodation,  c.  If  it  be 
nearer  to  the  page,  either  accommodation  must  be  used 
according  to  the  distance,  or  the  observer  must  withdraw 
his  head  further  from  the  lens.  d.  If,  keeping  the  lens 
quite  still,  the  observer  withdraw  his  head,  the  field  of  view 
will  be  lessened  (Fig.  13),  whilst  the  image  will  appear  to 
increase  in  size  (without  really  doing  so),  and  these  changes 
will  be  greater  the  nearer  the  lens  is  to  its  focal  distance 
from  the  paper  ;  if  it  be  almost  exactly  at  its  principal  focal 
distance,  only  a  very  small  part  of  the  print  will  be  seen 
when  the  head  is  withdrawn,  e.  If  the  head  be  moved  a 
little  from  side  to  side,  the  image  will  appear  to  move  in  the 
same  direction. 

The  emmetropic  eye,  with  the  accommodation  fully  re- 
laxed, being  adjusted  for  distant  objects,  i.  e.,  parallel  rays, 
receives  a  clear  image  of  such  objects  on  the  layer  of  rods 
and  cones  of  the  retina  (p.  25).  A  clear  image  of  the/tm- 
dus  of  the  eye,  i.  e.,  the  retina,  optic  disk,  and  choroid,  can 
be  obtained  in  such  an  eye  (as  in  the  second  experiment 
above  described,  when  the  distance  of  the  lens  from  the 
paper  was  equal  to  or  less  than  its  focal  length) ;  on  con- 
dition that  the  eyes,  both  of  patient  and  observer,  be  ad- 
justed for  infinite  distance,  i.  e.,  for  parallel  rays ;  in  other 


OPHTHALMOSCOPIC    EXAMINATION.  65 

words,  that  the  accommodation  of  both  be  relaxed.     The 
fundus  so  seen  is  magnified  about  15  diameters. 

In  order  to  use  the  ophthalmoscope1  it  is  first  necessary 
to  learn  to  manage  the  mirror  and  light.  (1)  Seat  the  pa- 
tient in  a  darkened  room  and  place  a  lamp  with  a  large 
steady  flame  on  a  level  with  his  eyes,  a  few  inches  from 
his  head,  and  about  in  a  line  with  his  ear.  The  lamp  may 
be  on  either  side,  but  is  usually  placed  on  his  left,  and  it  is 
better  to  keep  to  the  same  side  until  practice  has  given 
steadiness  to  the  various  combined  movements  which  are 
necessary.  (2)  Sit  down  in  front  of  the  patient  with  his 
face  fronting  your  own,  feature  to  feature.  It  is  most  con- 
venient for  the  observer's  face  to  be  a  little  higher  than 
that  of  the  patient.  (3)  Take  the  mirror  of  the  ophthal- 
moscope (without  any  lens  behind,  and  without  the  large 
lens)  in  your  left  hand  for  examining  the  patient's  left  eye 
(and  vice  versd  for  his  right  eye) ;  hold  it,  mirror  towards 
the  patient,  close  to  your  own  eye,  and  with  the  sight-hole 
placed  so  that  (with  your  other  eye  closed)  you  see  the  pa- 
tient through  it.  Now  rotate  the  mirror  slightly  towards 
the  lamp  until  the  light  reflected  from  the  flame  is  thrown 
into  the  patient's  pupil,  and  open  your  other  eye.  (4)  You 
will  so  far  have  seen  nothing  except  the  front  of  the  eye, 
unless  the  patient's  eye  is  under  atropine ;  for  he  will  have 
looked  at  the  centre  of  the  mirror,  and  his  pupil,  strongly 
contracted,  will  look  either  black  or  very  dull  red.  (5) 
Now  tell  him  to  look  steadily  a  little  to  one  side  into  va- 
cancy, or  at  an  object  on  the  other  side  of  the  room.  The 
pupil  will  now  become  red — bright  fiery  red,  if  it  be  rather 
large ;  a  duller  red  if  it  be  small,  or  the  patient  be  of  dark 
complexion.  In  one  position,  when  the  eye  under  exam- 
ination looks  a  little  inwards,  the  red  will  change  to  a 
yellowish  or  whitish  color,  and  this  indicates  the  position 

1  For  choice  of  instruments,  see  Appendix. 
6* 


66  OPHTHALMOSCOPIC    EXAMINATION. 

of  the  optic  disk.  (6)  Learn  to  keep  the  light  steadily  on 
the  pupil  during  slow  movements  backwards  and  forwards 
and  from  side  to  side  (taking  care  that  the  patient  keeps 
his  eye  all  the  time  in  the  same  position,  and  does  not  fol- 
low the  movements  of  the  mirror) ;  the  test  of  steadiness 
will  be  that  the  pupil  remains  of  a  good  red  color  in  all 
positions.  Up  to  this  point  the  examination  may  be  made 
without  atropine;  and  so  far  only  a  uniform  red  glare  will 
have  been  seen,  no  details  of  the  fundus  being  visible 
unless  the  patient  be  either  myopic  or  considerably  hyper- 
metropic. 

In  order  to  see  the  details  of  the  fundus  it  is  best  to  be- 
gin by  learning  the  Indirect  Method  (Fig.  30),  for,  though 
rather  less  easy  than  the  direct,  it  is  more  generally  useful. 

Having  learned  to  keep  the  light  reflected  steadily  into 
the  patient's  pupil,  take  the  mirror  without  any  lens  behind 
it  (unless  you  are  either  hypermetropic  or  myopic,  in  which 
case  you  should  either  wear  the  glasses  you  commonly  use 
for  reading,  or  place  a  lens  of  the  same  strength  in  the 
disk  behind  the  mirror)  in  one  hand,  and  one  of  the  large 
convex  "  objective"  lenses  in  the  other.  Always,  if  possi- 
ble, have  the  pupil  dilated  with  atropine,  for  by  this  means 
you  learn  to  see  the  fundus  much  more  quickly  and  easily. 
In  examining  the  patient's  right  eye,  apply  the  mirror  with 
your  right  hand  to  your  right  eye,  holding  the  lens  in  your 
left  hand;  it  is  best  to  reverse  everything  for  his  left  eye, 
but  the  position  of  the  light  need  not  be  changed.  The 
hand  which  carries  the  lens  should  be  steadied  by  resting 
the  little  or  ring  finger  against  the  patient's  eyebrow  or 
temple. 

It  is  best  to  begin  by  looking  for  the  optic  disk,  which  is 
one  of  the  most  important  and  easily  seen  parts.  To  bring 
it  into  view  the  patient  must  look  a  little  inwards  with  the 
eye  under  examination,  e.  g.,  if  his  right  eye  is  under  ex- 
amination he  must  direct  it  to  the  observer's  right  ear,  or 


OPHTHALMOSCOPIC    EXAMINATION. 


67 


68  OPHTHALMOSCOPIC    EXAMINATION. 

look  at  the  little  finger  of  his  mirror's  hand.  Take  care 
that  the  patient  turns  his  eye,  not  his  head,  in  the  required 
direction.  The  lens  should  be  held  about  2"-3",  and  the 
observer  be  about  18"  from  the  patient's  eye;  the  image  of 
the  fundus  being  formed  in  the  air  2"  or  3"  in  front  of  the 
lens,  will  thus  be  situated  about  12"  from  the  observer. 

The  bright  red  glare  (from  the  choroid)  will  be  obvious 
enough ;  but  most  beginners  find  some  difficulty  in  avoid- 
ing the  reflection  of  the  mirror  from  the  cornea,  and  in  ad- 
justing the  accommodation  and  the  distance  of  the  head  so 
as  to  see  the  image  clearly.  The  head  must  be  slowly 
moved  a  little  further  from  or  nearer  to  the  patient,  and  at 
the  same  time  an  attempt  made  to  adjust  the  eyes  (both 
being  kept  open)  for  a  point  between  the  observer  and  the 
lens.  Several  sittings  are  sometimes  necessary  before  the 
image  of  the  optic  disk,  or  retinal  vessels,  can  be  clearly 
seen. 

The  optic  disk — ending  of  the  optic  nerve  in  the  eye 
above  the  lamina  cribrosa,  optic  papilla  (Figs.  31  and  33) — 
is  seen  as  a  round  object,  of  much  lighter  color  than  the 
fiery  red  of  the  surrounding  fundus,  and  with  numerous 
bloodvessels  radiating  from  its  centre  chiefly  in  an  upward 
and  downward  direction.  As  soon  as  the  disk  can  be  easily 
seen,  the  student  must  pass  on  to  the  study  of  the  most  im- 
portant details  of  this  part  itself  and  of  the  other  parts  of 
the  fundus,  some  of  which  will  be  given  here  and  others 
will  be  found  in  the  chapters  on  the  Diseases  of  the  Choroid 
and  Retina,  and  on  the  Errors  of  Refraction. 

The  disk,  as  a  whole,  is  of  a  grayish-pink,  with  admix- 
ture of  yellow.  It  is  nearly  circular,  but  seldom  perfectly 
so,  being  often  apparently  oval  or  slightly  irregular.  Two 
differently  colored  parts  are  noticeable — a  central  patch, 
whiter  than  the  rest,  and  into  which  most  of  the  blood- 
vessels dip ;  and  a  surrounding  part  of  pink  or  grayish- 
pink.  In  many  eyes,  especially  in  old  persons,  the  appar- 


OPHTHALMOSCOPIC    EXAMINATION.  69 

ent  boundary  of  the  disk  is  formed  by  a  narrow  line  of 
lighter  color,  which  represents  the  border  of  the  sclerotic 
(scleral  ring).  The  bloodvessels  consist  of  several  large 
trunks  and  a  varying  number  of  small  twigs;  the  large 
trunks  emerge  from  the  central  white  part  of  the  disk,  and 
often  bifurcate  once  or  twice  on  its  area ;  the  small  twigs 
may  emerge  separately  from  various  parts  of  the  disk,  or 
form  branches  of  the  large  trunks. 

Variations. — The  color  of  the  disk  appears  paler  or 
darker  according  to  the  color  of  the  surrounding  choroid, 
the  brightness  of  the  light  used,  and  the  patient's  age  and 
state  of  health.  A  curved  line  of  dark  pigment  often 
bounds  a  part  of  the  circumference  of  the  disk  and  has  no 
pathological  meaning.  The  central  white  patch  varies 
greatly  in  size,  position,  and  distinctness ;  it  may  be  so 
small  as  hardly  to  be  perceptible,  or  very  large ;  may  shade 
off  gradually  or  be  abruptly  denned  ;  may  be  central  or 
eccentric ;  when  large  it  generally  shows  a  grayish  stippling 
or  mottling.  The  white  patch  itself  represents  a  depression 
of  corresponding  position  and  size,  the  physiological  cup  or 
pit  (compare  Figs.  33  and  34)  formed  by  the  nerve-fibres 
radiating  from  the  centre  of  the  disk  on  all  sides  towards 
the  retina,  like  the  tentacles  of  an  open  sea-anemone,  and 
through  it  the  chief  bloodvessels  pass  on  their  way  between 
the  nerve  and  the  retina.  This  depression  is  generally 
shaped  like  a  funnel  or  a  dimple  with  gradually  sloping 
sides  (Fig.  34) ;  but  sometimes  the  sides  are  steep,  or  even 
over-hanging ;  in  other  eyes  it  is  wide  or  shallow,  and  en- 
larged towards  the  outer  side  of  the  disk.  The  physiolog- 
ical pit  is  whiter  than  the  rest  of  the  disk,  because  the 
grayish-pink  nerve-fibres  are  absent  at  this  part,  and  we 
can  therefore  see  down  to  the  opaque,  white,  fibrous  tissue 
which,  under  the  name  of  lamina  cribrosa,  forms  the  floor 
of  the  whole  disk  (Fig.  34).  The  stippled  appearance  often 
noticed  in  the  pit  is  caused  by  the  holes  in  this  lamina, 


70  OPHTHALMOSCOPIC    EXAMINATION. 

through  which  the  bundles  of  nerve-fibres  pass  on  their 
way  to  the  retina,  the  holes  appearing  darker  because 
-filled  by  non-medullated  nerve-fibres,  which  reflect  but 
little  light. 

The  other  parts  of  the  fundus. — The  groundwork  is  of 
a  bright  fiery  red  (the  choroid,  not  the  retina),  which  iu 
average  eyes  is  nearly  uniform,  but  in  persons  of  very 
light  or  very  dark  complexion  shows  a  pattern  of  closely- 
set  tortuous  red  bands  (vessels),  separated  by  interspaces 
either  of  darker  or  of  lighter  color  (Fig.  31).  (For  fur- 
ther details,  see  Diseases  of  Choroid.) 

Upon  this  red  ground  the  vessels  of  the  retina  divide 

FIG.  31. 


Opbthalmoscopic  appearance  of  healthy  fundus  in  a  person  of  very  fair 
complexion.     (Wecker  and  Jaeger.) 

and  subdivide  dichotomously.  It  will  be  noticed  that  the 
principal  trunks  pass  almost  vertically  upwards  and  down- 
wards, but  that  no  large  branches  go  to  the  part  apparently 
inwards  from  the  disk  ;  that  the  whole  number  of  visible 
retinal  vessels  is  comparatively  small,  large  spaces  inter- 


OPHTHALMOSCOPIC    EXAMINATION.  71 

vening  between  them ;  that  they  become  progressively 
smaller  as  they  recede  from  the  optic  disk  ;  and  that  they 
never  anastomose  with  each  other.  Special  attention  must 
be  given  to  the  part,  apparently  to  the  inner  (nasal)  side 
of  the  optic  disk  (really  to  its  outer  temporal  side),  which 
is  the  region  of  most  accurate  vision,  the  yellow  spot  (y.  s., 
macula  lutea,  or  shortly  "  macula  ").  This  region  is  skirted 
by  large  vessels  from  which  numerous  twigs  are  given  off 
to  it.  The  y.  s.  is  seen  when  the  patient  looks  straight  at  the 
ophthalmoscope  ;  it  will  be  noticed  that  the  choroidal  red  is 
darker  at  this  part,  and  that  no  retinal  vessels  pass  across 
its  centre,  but  that  numerous  fine  twigs  radiate  to  and  from 
it  (see  Chap.  XIV.).  In  many  eyes  nothing  but  these  in- 
definite characters  mark  the  y.  s. ;  but  in  some,  especially 
in  dark  eyes  and  young  patients,  a  minute  bright  dot  oc- 
cupies its  centre,  and  is  encircled  by  an  ill-bounded  dark 
area,  round  which  again  a  characteristic  shifting  white 
halo  is  seen.  The  minute  dot  is  the  fo  vea  centralis,  the 
thinnest  part  of  the  retina.  The  neighborhood  of  the  disk 
and  y.  s.  form  the  central  region  of  the  fundus.  The  pe- 
ripheral parts  are  explored  by  telling  the  patient  to  look 
successively  up,  down,  and  to  each  side  without  moving  his 
head.  To  see  the  extreme  periphery  the  observer  must 
move  his  head  as  well  as  the  patient  his  eye.  Towards  the 
periphery  the  choroidal  trunk-vessels  are  often  plainly  visi- 
ble when  none  were  distinguishable  at  the  more  central 
parts. 

The  vessels  of  the  retina  (see  Chap.  XIV.)  are  easily 
distinguished  from  those  of  the  choroid  by  their  course 
and  mode  of  branching,  and  by  the  small  size  of  all  except 
the  main  trunks ;  but  especially  by  their  greater  sharpness 
of  outline  and  clearness  of  tint,  and  by  the  presence  of  a 
light  streak  along  the  centre  of  each  (Fig.  31),  which  gives 
them  an  appearance  of  roundness,  very  different  from  the 
flat  band-like  look  of  the  choroidal  vessels.  They  are  di- 


72  OPHTHALMOSCOPIC    EXAMINATION. 

visible  into  two  sets — a  darker,  larger,  somewhat  tortuous 
set — the  veins ;  and  a  lighter,  brighter  red,  smaller,  and 
usually  straighter  set — the  arteries,  the  diameter  of  cor- 
responding branches  being  about  as  3  to  2.  The  arteries 
and  veins  run  pretty  accurately  in  pairs.  Pressure  on  the 
eyeball,  through  the  upper  lid,  causes  visible  pulsation  of 
the  arteries  on  the  disk. 

The  indirect  method  of  examination  is  most  generally 
useful,  because  it  gives  a  large  field  of  view,  under  a  com- 
paratively low  magnifying  power  (about  three  to  five 
diameters).  The  general  character  and  distribution  of 
any  morbid  changes  are  better  appreciated  than  if  we 
begin  with  the  direct  method,  in  which  the  field  of  view 
is  smaller  and  the  magnifying  power  much  greater.  It 
has  also  the  great  advantage  of  being  equally  applicable 
in  all  states  of  refraction  in  the  patient,  whereas  in  myopia 
the  fundus  cannot  be  examined  by  the  direct  method  with- 
out the  aid  of  a  suitable  concave  lens,  found  experiment- 
ally, placed  behind  the  mirror  (p.  76).  In  the  inverted 
image  the  inversion  is  such  that  what  appears  to  be  upper 
is  lower,  and  what  appears  to  be  R.  is  L. 

The  Direct  Method,  i.  e.,  examination  by  the  mirror  alone, 
or  with  the  addition  of  a  lens  in  the  clip  or  disk  behind  it, 
but  without  the  intervention  of  the  large  lens. 

By  this  method  the  parts  (unless  the  eye  be  myopic)  are 
seen  in  their  true  position  (Fig.  32),  the  upper  part  of  the 
image  corresponding  to  the  upper  part  of  the  fundus,  the 
right  to  the  right,  etc.,  it  is  therefore  often  called  the 
method  of  the  "erect"  or  "upright"  image;  though,  as 
will  be  seen  below,  these  terms  are  not  strictly  convertible 
with  "direct  examination."  It  is  used  (1)  to  detect  opaci- 
ties in  the  vitreous  humor  and  detachments  of  the  retina  ; 
(2)  To  ascertain  the  condition  of  the  patient's  refraction, 
i.  e.,  the  relation  of  his  retina  to  the  focus  of  his  lens-sys- 


OPHTHALMOSCOPIC    EXAMINATION.  73 

tern ;  (3)  For  the  minute  examination  of  the  fundus  by  the 
highly  magnified,  virtual  erect  image  (Fig.  33). 

(1)  To  examine  the  vitreous  humor.     The  patient  is  to 
move  his  eye  freely  in  different  directions  whilst  the  light 
is  reflected  into  the  eye  from  a  distance  of  a  foot  or  more 
(for  details,  see  Diseases  of  Vitreous)  ;  detachments  of  the 
retina  are  seen  in  the  same  way.     Opacities  in  the  vitreous 
and  folds  of  detached  retina,  being  situated  far  within  the 
focal  length  of  the  refractive  media,  are  seen  in  the  erect 
position  under  the  conditions  mentioned  at  p.  64,  c.,the 
observer  being  at  a  considerable  distance  from  the  eye. 

(2)  To  ascertain  the  kind  of  refraction.     If  when  using 
the  mirror  alone,  at  a  distance  of  18"  or  more  from  the  pa- 
tient's eye,  we  see  some  of  the  retinal  vessels  clearly  and 
easily,  the  eye  is  either  myopic  or  hypermetropic.    If,  when 
the  observer's  head  is  moved  slightly  from  side  to  side,  the 
vessels  seem  to  move  in  the  same  direction,  the  image  seen 
is  a  virtual  one  and  the  eye  hypermetropic.     The  eye  is 
myopic  if  the  vessels  seem  to  move  in  the  contrary  direc- 
tion ;  the  image  in  myopia  is,  indeed,  formed  and  seen  in 
the  same  way  as  the  inverted  image  seen  by  the  "  indirect" 
method  of  examination,  but  except  in  the  highest  degrees 
of  myopia  it  is  too  large  and  too  far  from  the  patient  to  be 
available  for  detailed  examination.     In  low  degrees  of  M. 
this  inverted  image  is  formed  so  far  in  front  of  the  patient's 
eye  as  to  be  visible  only  when  the  observer  is  distant  per- 
haps 3'  or  4' ;  whilst  in  E.  and  in  lower  degrees  of  H.  the 
erect  image  will  not  be  easily  seen  at  a  greater  distance 
than  12"  or  18"  (p.  64,  d.,  and  Fig.  13).     If,  therefore,  in 
order  to  get  a  clear  image  by  the  direct  method,  the  ob- 
server has  to  go  either  very  close  to,  or  a  long  way  from, 
the  patient,  no  great  error  of  refraction  can  be  present. 

The  above  tests  only  reveal  qualitatively  the  presence  of 
either  M.  or  H.,  but  by  a  modification  of  the  method,  the 
exact  quantity  of  any  error  of  refraction,  e.  g.,  H.,  can  be 

7 


74 


OPHTHALMOSCOPIC    EXAMINATION. 


OPHTHALMOSCOPIC    EXAMINATION.  75 

determined  with  great  accuracy  (determination  of  the  refrac- 
tion by  the  ophthalmoscope).  In  E.,  as  already  stated  at  pp. 
64,  65,  the  erect  image  can  be  seen  only  if  the  observer  be 
near  to  the  patient,  and  also  completely  relax  his  accom- 
modation ;  for,  in  experiment  d.  there  described,  when  the 
head  was  withdrawn  from  the  lens  the  magnifying  power 
appeared  to  increase,  whilst  the  field  of  view  and  illumina- 
tion rapidly  diminished.  The  same  occurs  with  the  eye, 
but  in  a  much  greater  degree,  and  hence  in  E.  no  useful 
view  can  be  gained  except  near  to  the  eye. 

In  H.,  where  the  retina  is  within  the  focus  of  the  lens- 
system,  the  erect  image  is  seen  when  close  to  the  patient's 
eye  only  by  an  effort  of  accommodation  in  the  observer, 
just  as  in  the  same  experiment  when  the  lens  was  within 
its  focal  length  from  the  page  (p.  64,  c.).  And  as  in  that 
experiment  the  print  was  also  seen  easily,  even  when  the 
head  was  withdrawn,  so  in  H.  the  erect  image  is  seen  at  a 
distance  as  well  as  close  to  the  patient. 

If  now  the  observer,  instead  of  increasing  the  convexity 
of  his  crystalline,  place  a  convex  lens  of  equivalent  power 
behind  his  ophthalmoscope  mirror,  this  lens  will  be  a 
measure  of  the  patient's  H.,  i.  e.,  it  will  be  the  lens  which, 
when  the  patient's  accommodation  is  in  abeyance,  will  be 
needed  to  bring  parallel  rays  to  a  focus  on  his  retina.  If 
a  higher  lens  be  used,  the  result  will  be  the  same  as  when 
in  the  experiment  the  convex  lens  was  removed  beyond  its 
focal  length  from  the  print ;  the  fundus  will  be  more  or  less 
blurred. 

Hence  to  measure  H. :  (1)  the  accommodation  of  both 
patient  and  observer  must  be  fully  relaxed  (usually  by 
atropine  in  the  patient  and  by  voluntary  effort  in  the  ob- 
server) ;  (2)  The  observer  must  go  as  close  as  possible  to 
the  patient;  (3)  he  must  then  place  convex  lenses  behind 
his  mirror,  beginning  at  the  weakest  and  increasing  the 
strength  till  the  highest  is  reached  with  which  the  details 


76  OPHTHALMOSCOPIC    EXAMINATION. 

of  the  optic  disk  can  be  seen  with  perfect  clearness.  By 
practice  the  distance  between  the  cornese  of  patient  and 
observer  may  be  reduced  to  about  J".  The  light  must  be 
on  the  same  side  as  the  eye  under  examination,  so  as  to 
avoid  much  rotation  of  the  mirror.  The  right  eye  must 
examine  the  right,  and  vice  versa. 

In  the  same  way,  though  with  less  accuracy  in  the  high 
degrees,  M.  can  be  measured  by  means  of  concave  lenses ; 
the  lowest  lens  with  which  an  erect  image  is  obtained  being 
the  measure  of  the  M. 

Astigmatism  (As.)  may  also  be  measured  by  this  method, 
the  refraction  being  estimated  first  in  one  and  then  in  the 
other  of  the  two  chief  meridians  by  means  of  correspond- 
ing retinal  vessels  (see  Astigmatism). 

FIG.  33. 


Ophthalmoscopio  appearance  of  healthy  disk,  as  seen  in  the  erect  image. 
Dark  vessels,  veins;  double  contoured  vessels,  arteries.  X  15  diameters 
(after  Jaeger). 

This  application  of  the  direct  method  needs  much  prac- 
tice, and  for  convenience  the  lenses,  of  which  there  are 
twenty  or  more,  are  placed  in  a  thin  metal  disk,  which  can 
be  revolved  behind  the  mirror  so  as  to  bring  each  lens  in 
succession  opposite  the  sight-hole.  There  are  many  forms 
of  these  "refraction  ophthalmoscopes,"  varying  in  minor 
details  of  construction  (see  Appendix). 


OPHTHALMOSCOPIC    EXAMINATION. 


77 


(3)  The  erect  image  is  very  valuable,  on  account  of  the 
high  magnifying  power  (about  15  diameters  in  the  E.  eye) 
for  the  examination  of  the  finer  details  of  the  fuudus.  The 
disk  looks  less  sharply  defined  because  more  magnified  than 
when  seen  by  the  indirect  method ;  both  the  disk  and  the 

FIG.  34. 


Vertical  section  of  healthy  optic  disk,  etc.  X  about  15.  7?.  Retina, 
outer  layers  shaded  vertically,  nerve-fibre  layer  shaded  longitudinally. 
Ch.  Choroid.  Set.  Sclerotic.  L,  Or.  Lamina  cribrosa.  S.  V.  Subvaginal 
space  between  outer  and  inner  sheath  of  optic  nerve.  The  central  vein 
and  a  main  division  of  the  central  artery  are  seen  in  the  nerve  and  disk. 

retina  often  show  a  faint  radiating  striation  (the  nerve- 
fibres)  ;  the  lamina  cribrosa  is  often  more  brilliantly  white; 
and  the  pigment  epithelium  of  the  choroid  can  be  recog- 
nized as  a  fine  uniform  dark  stippling. 

If  the  refraction  be  E.  or  H.,  no  lens  is  needed  behind 
the  mirror ;  if  M.,  a  concave  lens  must  be  placed  in  the 
clip  behind  the  mirror,  of  sufficient  strength  to  give  a  good, 
clear,  erect  image.  The  observer  must  come  as  near  as 
possible  to  the  patient. 

By  reference  to  Fig.  32  it  will  be  seen  that  only  those 
rays  are  useful  which  strike  near  the  centre  of  the  mirror, 
none  others  entering  the  patient's  pupil ;  hence,  if  the  aper- 
ture in  the  mirror  be  too  large,  the  fundus  will  not  be  well 

7* 


78  OPHTHALMOSCOPIC    EXAMINATION. 

lighted.  It  should  not  be  larger  than  3  mm.,  whilst  if 
much  smaller  than  that  the  image  has  a  fictitious  clearness 
which  in  some  cases  would  be  misleading. 

KETINOSCOPY  (KERATOSCOPY). 

If  the  fundus  be  lit  up  by  the  ophthalmoscope  mirror 
from  a  distance,  slight  rotation  of  the  mirror  between  the 
finger  and  thumb  causes  a  dark  shadow  to  pass  across  the 
red  field.  The  edge  of  the  shadow  has  the  same  direction 
as  the  axis  on  which  the  mirror  is  turned.  In  emmetropia, 
hypermetropia,  and  very  low  myopia,  the  shadow  moves  in 
a  direction  opposite  to  that  in  which  the  mirror  is  rotated  ; 
in  myopia  of  1  D.  and  more  it  moves  in  the  same  direction 
as  the  mirror. 

The  higher  the  degree  of  H.  or  M.  the  fainter  is  the  illu- 
mination, the  more  crescentic  the  shadow,  and  the  slower 
its  movement;  the  lower  the  defect  the  brighter  is  the 
lighted  area,  the  more  linear  the  shadow,  and  the  quicker 
its  motion.  By  placing  trial  lenses  in  front  of  the  patient's 
eye  ( —  if  the  shadow  move  with  the  mirror,  showing  de- 
cided M. ;  -j-  if  it  move  against  the  mirror,  generally  show- 
ing decided  H.)  we  can  estimate  the  degree  of  M.  or  H. 
In  M.  we  find  experimentally  the  weakest  —  lens,  which 
makes  the  shadoAV  move  against  the  mirror ;  and  since  this 
movement  is  still  compatible  with  very  slight  M.,  we  say 
that  the  M.  is  greater  by  (.5  D.)  than  the  chosen  lens  indi- 
cates. In  H.  we  find  the  weakest  -f-  lens,  which  makes  the 
shadow  move  with  the  mirror ;  and  as  this  movement  shows 
at  least  1  D.  of  M.,  the  H.  is  less  by  1  D.  than  the  lens  in- 
dicates. The  chief  meridians  in  astigmatism  may  be  ascer- 
tained by  observing  that  when  one  meridian  is  as  nearly  as 
possible  corrected  by  a  spherical  lens,  the  shadow  shows  by 
its  characters  a  decided  error  of  refraction  in  the  opposite 
meridian  ;  and  the  degree  of  As.  is  shown  by  the  cylindri- 


OPHTHALMOSCOPIC    EXAMINATION.  79 

cal  lens  (-)-  or  — ),  which,  with  its  axis  parallel  to  the 
border  of  this  shadow,  corrects  the  error. 

For  retinoscopy  a  concave  mirror  of  9"  (22  cm.)  focus  is 
to  be  used,  at  a  distance  of  4'  (120  cm.)  from  the  patient, 
and  the  pupil  is  to  be  dilated  by  atropine.  The  light  is  to 
be  thrown  as  nearly  as  possible  in  the  direction  of  the 
visual  axis.  The  method  is  useful,  especially  for  children, 
and  is  said  after  a  little  practice  to  be  both  quick  and 
accurate  ;  though  I  have  not  yet  tried  it  largely,  I  have 
several  times  found  it  useful.  For  further  details  the  reader 
is  referred  to  Mr.  Morton's  excellent  little  work,  which 
contains  the  best  account  of  the  subject  in  our  language.1 

1  A.  Stanford  Morton,  Kefraction  of  the  Eye,  its  Diagnosis,  etc., 
1881,  chap. ix. 


PART  II. 

CLINICAL    DIVISION. 


CHAPTER   V. 

DISEASES    OF    THE    EYELIDS. 

THE  border  of  the  lid,  which  contains  the  Meibomian 
glands,  the  follicles  of  the  eyelashes,  and  certain  modified 
sweat-glands  and  sebaceous  glands,  is  often  the  seat  of 
troublesome  disease.  Being  half  skin  and  half  mucous 
membrane,  it  is  moist  and  more  susceptible  than  the  skin 
itself  to  irritation  by  external  causes  ;  being  a  free  border, 
its  circulation  is  terminal,  and  therefore  especially  liable  to 
stagnation.  Its  numerous  and  deeply-reaching  glandular 
structures,  therefore,  furnish  an  apt  seat  for  chronic  inflam- 
matory changes. 

Blepharitis  (ophthalmia  tarsi,  tinea  tarsi,  sycosis  tarsi) 
includes  all  cases  in  which  the  border  of  the  eyelid  is  the 
seat  of  subacute  or  chronic  inflammation.  There  are  sev- 
eral types.  The  skin  is  not  much  altered,  but  chronic 
thickening  of  the  conjunctiva  near  the  border  of  the  lid  is 
generally  observed.  The  disease  may  affect  both  lids  or 
only  one,  and  the  whole  length  or  only  a  part. 

In  the  commonest  and  most  troublesome  form  the  glands 
and  eyelash-follicles  are  the  principal  seats  of  the  disease. 
The  symptoms  are  firm  thickening  and  dusky  congestion  of 
the  border  region,  with  exudation  of  sticky  secretion  from 

(81) 


82        DISEASES  OF  THE  EYELIDS. 

its  edge,  gluing  the  lashes  together  into  little  pencils.  Very 
mild  cases  present  merely  overgrowth  of  lashes  and  excess 
of  Meibomian  secretion.  But  generally  the  disease  pro- 
gresses ;  little  excoriations  and  ulcers  covered  by  scab  form 
along  the  free  border,  and  often  minute  pustules  appear; 
the  thickening  and  vascularity  increase;  the  lashes  are 
loosened,  and  free  bleeding  occurs  when  they  are  pulled  out. 
After  months  or  years  of  varying  activity  some  or  all  of  the 
hair-follicles  become  altered  in  size  and  direction,  or  quite 
obliterated ;  and  stunted,  misplaced,  or  deficient  lashes,  are 
the  result;  as  the  thickening  gradually  disappears,  little 
lines,  or  thin  seams,  of  scar  are  seen  just  within  the  edge 
of  the  lid,  slight  eversion  being  often  the  result.  The  re- 
sulting exposure  of  the  marginal  conjunctiva,  together  with 
the  deficiency  of  lashes,  causes  the  disagreeably  raw  and 
bald  appearance  termed  lippitudo.  Epiphora,  from  ever- 
sion, tumefaction,  or  narrowing  of  the  puncta,  is  a  common 
result  in  these  bad  cases.  Often,  however,  the  disease  leads 
to  nothing  wrorse  than  the  permanent  loss  of  a  certain  num- 
ber of  the  lashes. 

In  another  type  the  changes  are  quite  superficial — mar- 
ginal eczema ;  the  patient  is  liable,  perhaps  through  life,  to 
soreness  and  redness  of  the  borders  of  the  lids,  little  crusts 
and  scales,  and  sometimes  pustules,  form  at  the  roots  of  the 
lashes,  whose  growth,  however,  is  not  interfered  with.  In 
such  people  the  eyes  look  weak  or  tender ;  the  condition  is 
made  worse  by  exposure  to  heat,  dust,  and  wind,  and  by  long 
spells  of  work. 

Ophthalmia  tarsi  generally  begins  in  childhood,  and  an 
attack  of  measles  is  the  commonest  exciting  cause.  It  sel- 
dom becomes  severe  or  persistent  except  from  neglect  of 
cleanliness  combined  with  a  sluggish  circulation;  the  pa- 
tients are  generally  ansemic,  and  often  scrofulous,  and  the 
condition  is  then  often  the  result  of  some  previous  more 
acute  ophthalmia.  In  adults  severe  sycosis  of  the  eyelids 


DISEASES  OF  THE  EYELIDS.        83 

may  accompany  sycosis  of  the  beard,  but,  as  a  rule,  no  ten- 
dency to  such  disease  of  the  skin  is  observed. 

TREATMENT. — When  the  inflammatory  symptoms  are  se- 
vere nothing  has  such  a  marked  effect  as  pulling  out  all  the 
lashes.  Cases  of  a  few  weeks'  standing  may  be  cured  by 
one  or  two  such  epilations,  together  with  local  remedies, 
and  in  old  cases  it  gives  great  relief  in  the  relapses  which 
are  so  common.  Local  applications  are  always  needed  (1) 
for  the  removal  of  the  scabs,  (2)  to  subdue  the  inflamma- 
tory symptoms.  A  warm  alkaline  and  tar  lotion,  with 
which  the  lids  are  to  be  carefully  soaked  for  a  quarter  of 
an  hour  night  and  morning,  followed  by  a  weak  mercurial 
ointment  applied  along  the  edges  of  the  lids  after  each 
bathing,  is  an  efficient  plan  if  the  mother  will  take  pains. 
In  bad  cases  painting  or  pencilling  the  border  of  the  lid 
with  nitrate  of  silver,  either  in  strong  solution,  or  the  di- 
luted stick,  or  the  use  of  weak  silver  lotion  is  very  useful 
in  addition  to  the  ointment.  In  old  cases  with  much  epi- 
phora the  canaliculus  is  to  be  slit  up.  The  patients  gener- 
ally need  a  long  course  of  iron  (F.  1,  2,  3;  13,  14;  18, 
19,  20). 

A  stye  is  the  result  of  suppurative  inflammation  of  the 
connective  tissue,  or  of  one  of  the  glands  in  the  margin  of 
the  lid.  Owing  to  the  close  texture  of  the  tarsus  and  the 
vascularity  of  the  parts,  the  pain  and  swelling  are  often 
disproportionately  severe  and  even  alarming  to  the  patient. 
The  matter  generally  points  around  an  eyelash;  but  if 
seated  in  a  Meibomian  gland,  it  may  point  either  to  its 
opening  on  the  border  of  the  lid  or  to  the  conjunctiva, 
rarely  to  the  skin. 

Styes  almost  always  show  some  derangement  of  health. 
Overuse  of  the  eyes,  especially  if  hypermetropic,  is  the 
exciting  cause  in  some  cases;  exposure  to  cold  wind  in 
others.  Styes  are  very  apt  to  occur  one  after  another  in 
successive  crops  for  several  weeks. 


84        DISEASES  OF  THE  EYELIDS. 

TREATMENT. — A  stye  may  sometimes  be  cut  short  if  seen 
quite  early,  by  the  vigorous  use  of  an  antiphlogistic  lotion. 
A  little  later  the  attack  may  be  shortened  by  thrusting  a 
fine  point  of  nitrate  of  silver  into  the  orifice  of  the  gland 
if  this  can  be  identified,  the  corresponding  eyelash  being 
first  drawn  out.  But  often  poulticing  gives  most  relief 
until  the  stye  points,  when  it  should  be  opened.  The 
health  always  needs  attending  to,  and  a  purgative  iron 
mixture  often  suiis  better  than  anything  else. 

Some  persons  are  subject  to  very  small  pustules  or  styes 
much  more  superficial  than  the  above,  and  less  closely  asso- 
ciated with  derangement  of  health. 

A  Meibomian  gland  is  often  the  seat  of  chronic  over- 
growth, a  little  tumor  in  the  substance  of  the  lid  being  the 
result  (Meibomian  cyst,  chalazion).  In  a  few  weeks  or 
months  the  growth  becomes  as  large  as  a  pea,  forming  a 
firm,  hemispherical,  painless  swelling  beneath  the  skin.  It 
generally  causes  thinning  of  the  tissues  towards  the  con- 
junctiva, and  is  then  recognizable  by  a  dusky  patch  on  the 
inner  surface  of  the  lid.  The  deeper  part  of  the  gland  is 
generally  affected,  the  border  of  the  lid  remaining  healthy; 
and  even  if  the  tumor  happen  to  be  close  to  the  border,  it 
is  usually  of  small  size.  The  skin  is  freely  movable  over 
the  tumor,  but  occasionally  the  growth  pushes  forwards  and 
adhesion  occurs ;  even  then  it  is  easily  distinguished  from 
a  sebaceous  cyst  by  the  firmness  of  its  deep  attachment. 
During  its  course  the  cyst  may  inflame  and  even  suppurate, 
and  in  the  latter  case  it  forms  one  variety  of  "stye."  The 
same  tumor  may  inflame  several  times,  and  finally  suppu- 
rate and  shrink.  Like  styes,  these  tumors  are  apt  to  con- 
tinue forming  one  after  another.  They  are  much  com- 
moner in  young  adults  than  earlier  or  later,  but  they  are 
now  and  then  seen  in  infants.  Patients  as  often  apply  for 
the  disfigurement  as  for  any  discomfort  which  these  little 
growths  occasion. 


DISEASES  OF  THE  EYELIDS.         85 

TREATMENT. — The  cyst  is  to  be  removed  from  the  inner 
surface  of  the  lid ;  in  the  rare  cases  where  it  points  forwards 
the  incision  may  be  in  the  skin ;  it  never  recurs.  The  tu- 
mor generally  consists  of  a  soft,  pinkish,  gelatinous  mass, 
or  of  a  gruelly  or  puriform  fluid ;  there  is  no  cyst-wall. 
(See  Operations.) 

Small  yellow  dots  are  sometimes  seen  on  the  inner  surface 
of  the  lids,  due  to  little  cheesy  collections  in  the  Meibomian 
glands,  and  causing  irritation  by  their  hardness.  They 
should  be  picked  out  with  the  point  of  a  knife. 

Warty  formations  are  not  very  common  on  the  border 
of  the  lid,  and  are  of  little  consequence  except  in  elderly 
people,  when  they  should  be  looked  upon  with  suspicion  as 
possible  starting-points  of  rodent  cancer.  A  small  fleshy, 
yellowish-red,  flattened  growth  is  sometimes  met  with  just 
upon  the  tarsal  border,  and  apparently  seated  at  the  mouth 
of  a  Meibomian  gland.  It  causes  some  irritation,  and 
should  be  pared  off. 

Cutaneous  horns  are  occasionally  seen  on  the  skin  of 
the  eyelid;  small  pellucid  cysts  are  also  seen  on  the  lid 
border. 

Molluscum  contagiosum  is  partly  an  ophthalmic  disease, 
because  so  often  seated  upon  the  eyelids.  One  or  more  lit- 
tle rounded  prominences,  showing  a  small  dimpled  orifice 
at  the  top,  usually  plugged  by  dried  sebaceous  matter,  are 
seen  in  the  skin,  varying  from  the  size  of  a  mustard  seed 
to  a  cherry,  but  usually  not  larger  than  a  sweet  pea;  at 
first  they  are  hemispherical,  but  afterwards  become  con- 
stricted at  the  base.  The  skin  is  tightly  stretched,  thinned, 
and  adherent.  The  larger  specimens  sometimes  inflame} 
and  their  true  nature  may  then,  without  due  care,  be  mis- 
taken. Each  molluscum  must  be  removed,  the  white  lobu- 
lated,  gland-like  mass  which  forms  the  growth  being 
squeezed  out  through  the  incision  made  by  a  knife  or  scis- 
sors. 

8 


86         DISEASES  OF  THE  EYELIDS. 

Xanthelasma  palpebrarnm  appears  as  one  or  more  yel- 
low patches  like  pieces  of  washleather  in  the  skin,  varying 
from  mere  dots  to  the  size  of  a  kidney  bean,  quite  soft  in 
texture,  and  only  a  very  little  raised.  They  are  common- 
est near  the  inner  canthus,  and  unless  symmetrical  are 
usually  on  the  left  side.  They  occur  chiefly  in  elderly  per- 
sons who  have  previously  been  liable  to  become  often  very 
dark  around  the  eyes  when  out  of  health.  The  patches 
are  due  to  infiltration  of  the  deeper  parts  of  the  skin  by 
groups  of  cells  loaded  with  yellow  fat.  The  frequency  of 
xanthelasma  in  the  eyelids  is,  perhaps,  related  to  the  nor- 
mal presence  of  certain  peculiar  granular  cells,  some  of 
which  contain  pigment,  in  the  skin  of  these  parts. 

The  pediculus  pubis  (crab-louse),  if  it  happens  to  reach 
the  eyelashes  will  flourish  there.  The  lice  themselves  cling 
close  to  the  border  of  the  lid,  and  look  like  little  dirty 
scabs.  The  eggs  are  darkish,  and  may  also  be  mistaken 
for  bits  of  dirt.  The  absence  of  inflammation  and  the 
rather  peculiar  appearances  will  lead,  in  cases  of  doubt,  to 
the  use  of  a  magnifying  glass,  which  will  settle  the  question 
at  once. 

Ulcers  on  the  eyelids  may  be  malignant,  or  lupous,  or 
syphilitic,  and  in  the  last  case  the  sore  may  be  either  a 
chancre  or  a  tertiary  ulcer. 

Rodent  cancer  (rodent  ulcer,  flat  epithelial  cancer)  is  by 
far  the  commonest  form  of  carcinoma  affecting  the  eyelids, 
although  cases  are  occasionally  seen  of  which  both  the 
clinical  and  pathological  characters  are  those  of  ordinary 
epithelioma.  The  peculiarities  of  rodent  cancer  are,  that 
it  is  very  slow,  that  ulceration  almost  keeps  pace  with  the 
new  growth,  and  that  it  does  not  cause  infection  of  lym- 
phatics. It  seldom  begins  before,  generally  not  until  con- 
siderably after,  middle  life,  and  its  course  often  extends 
over  many  years.  Beginning  as  a  "pimple"  or  "wart," 
it  slowly  spreads,  but  some  years  may  pass  before  the  ulcer 


DISEASES  OF  THE  EYELIDS.         87 

is  as  large  as  a  sixpence.  When  first  seen  we  generally 
find  a  shallow  ulcer  involving  the  border  of  the  lid,  and 
covered  by  a  thin  scab.  It  is  bounded  by  a  raised  sinuous 
edge,  which  is  nodular  and  very  hard,  but  neither  inflamed 
nor  tender.  Slowly  extending  both  in  area  and  depth,  it 
attacks  all  tissues  alike,  finally  destroying  the  eyeball  and 
opening  into  the  nose.  In  a  few  very  chronic  cases  the 
disease  remains  quite  superficial,  and  cicatrization  may 
occur  at  some  parts  of  the  ulcerated  surface.  Now  and 
then  a  considerable  nodule  of  growth  forms  in  the  skin 
before  ulceration  begins. 

The  diagnosis  is  generally  quite  easy.  A  long-standing 
ulcer  of  the  eyelids  in  an  adult  is  nearly  certain  to  be 
rodent  cancer.  Tertiary  syphilitic  ulcers  are  much  less 
chronic,  more  inflamed  and  punched  out,  and  devoid  of 
the  very  peculiar  hard  edge  of  rodent  ulcer ;  moreover, 
they  are  very  uncommon.  Ltipus  seldom  occurs  so  late  in 
life  as  rodent  cancer,  presents  more  inflammation  and  much 
less  hardness,  and  is  often  accompanied  by  lupus  elsewhere 
on  the  cutaneous  or  mucous  surfaces.  Lupus  is  seldom 
difficult  to  distinguish  on  the  eyelids  from  tertiary  syphilis, 
the  latter  being  more  acute,  more  dusky,  and  showing  more 
loss  of  substance,  with  none  of  the  little,  ill-defined,  soft 
tubercles  seen  in  lupus. 

When  a  chancre  occurs  on  the  eyelid  the  induration  and 
swelling  are  usually  very  marked  ;  the  surface  is  abraded 
and  moist,  but  not  much  ulcerated  ;  the  glands  in  front  of 
the  ear  and  behind  the  jaw  become  much  enlarged.  The 
same  glands  enlarge,  either  with  or  without  suppuration, 
in  lupus,  and  in  many  inflammatory  conditions  of  the  lid. 

TREATMENT  OF  RODENT  CANCER. — Early  removal  is  of 
great  importance,  and  probably  the  more  so  in  proportion 
to  the  youth  of  the  patient.  Chloride  of  zinc  paste  or  the 
actual  cautery  is  necessary  in  addition  to  the  knife  in  bad 
cases;  scraping  may  also  be  employed.  The  disease  is 


88         DISEASES  OF  THE  EYELIDS. 

very  apt  to  return  locally.  Even  in  very  advanced  cases, 
where  complete  removal  is  impossible,  the  patient  may  be 
made  much  more  comfortable,  and  life  probably  prolonged, 
by  vigorous  and  repeated  treatment. 

Congenital  ptosis  is  a  not  very  rare  affection.  It  is  com- 
monly unilateral,  is  stated  to  have  been  present  at  birth, 
and  its  causation  is  unknown.  It  sometimes  diminishes 
markedly  in  the  first  few  years  of  life,  but  probably  sel- 
dom disappears.  It  is  customary  to  remove  an  elliptical 
piece  of  skin  from  the  lid,  and  improvement  is  gained,  es- 
pecially in  the  slighter  cases,  by  this  procedure.  Other 
more  severe  operations  have  also  been  devised. 

Epicanthus  is  a  rare  condition,  in  which  a  fold  of  skin 
stretches  across  from  the  inner  end  of  the  brow  to  the  side 
of  the  nose  and  hides  the  inner  canthus.  If  it  does  not 
disappear  as  the  child's  nose  develops,  an  operation — re- 
moval of  a  piece  of  skin  from  the  bridge  of  the  nose  (some- 
times combined  with  canthoplasty) — is  indicated. 


DISEASES    OF    LACHRYMAL    APPARATUS.       89 


CHAPTER    VI. 

DISEASES   OF   THE    LACHRYMAL   APPARATUS 

MAY  be  divided  into  those  which  affect  the  secreting 
parts — the  lachrymal  gland  and  its  ducts ;  and  those  in 
which  the  drainage  apparatus  is  at  fault — the  puncta, 
canaliculi,  lachrymal  sac,  and  nasal  duct.  In  the  great 
majority  of  cases  the  fault  lies  entirely  in  the  drainage 
system. 

The  flow  of  tears  over  the  edge  of  the  lid  and  down  the 
cheek  has  been  called  epiphora  when  due  to  over-secretion 
by  the  gland,  and  stilliddium  lacrymarwn  when  caused  by 
obstruction  to  an  outflow.  No  useful  purpose  is  served  by 
keeping  the  two  names,  and  only  the  former  will  be  here 
used.  Lachrymation  is  a  convenient  term  for  the  increased 
flow  which  accompanies  superficial  inflammation  of  the 
eyeball. 

(1)  The  lachrymal  gland  is  occasionally  the  seat  of 
acute  or  chronic  inflammation,  and  in  either  case  an  abscess 
may  form.  In  chronic  cases  the  enlarged  gland  is  dis- 
tinctly felt  projecting,  and  can  generally  be  recognized  by 
its  well-defined  and  lobulated  border;  but  the  enlargement 
cannot  always  be  distinguished  from  that  caused  by  a  mor- 
bid growth  in  the  gland  or  corresponding  part  of  the  orbit. 
In  acute  inflammation  there  are  the  usual  signs — local  heat, 
tenderness,  and  pain  with  swelling  which  may  obscure  the 
boundaries  of  the  gland.  If  the  enlargement  be  great, 
the  eyeball  is  displaced,  and  the  oculo-palpebral  fold  of 
conjunctiva  in  front  of  the  gland  is  pushed  downwards, 
and  projects  more  or  less  between  the  lid  and  the  eye. 

8* 


90       DISEASES    OF    LACHRYMAL    APPARATUS. 

When  an  abscess  forms  it  may  sometimes  be  opened  from 
the  conjunctiva,  but  more  often  it  points  to  the  skin, 
through  which  the  incision  must  then  be  made.  If  it  be 
allowed  to  burst  spontaneously  through  the  skin  a  trouble- 
some fistula  may  follow. 

A  little  abscess  sometimes  forms  in  one  of  the  separate 
anterior  lobules,  the  main  body  of  the  gland  remaining 
free.  There  is  limited  swelling  and  tenderness  of  the  lid 
at  the  upper  outer  angle,  not  passing  back  beneath  the 
orbital  rim ;  the  abscess  points  through  the  conjunctiva, 
above  the  outer  end  of  the  tarsal  cartilage,  and  is  thus  dis- 
tinguished from  a  suppurating  Meibomian  cyst.  Very 
rarely  cystic  distention  of  one  or  more  of  the  gland-ducts  is 
seen  in  the  form  of  a  bluish,  semi-transparent  swelling 
(Dacryops),  just  beneath  the  conjunctiva  of  the  lid  at  the 
upper  outer  part.  No  change  in  the  lachrymal  secretion 
appears  to  have  been  noticed  in  cases  of  paralysis  of  the 
cervical  sympathetic  nerve. 

(2)  The  drainage  system  may  be  at  fault  in  any  part 
from  the  puncta  to  the  lower  end  of  the  nasal  duct. 

The  slightest  change  in  the  position  of  the  lower  punctum 
causes  epiphora.  In  health  the  punctum  is  directed  back- 
wards against  the  eye ;  if  it  look  upwards  or  forwards  the 
tears  do  not  all  reach  it,  and  some  will  then  flow  over  a 
lower  part  of  the  lid.  In  paralysis  of  the  facial  nerve  the 
patient  sometimes  comes  to  us  for  epiphora ;  the  symptom 
is  caused  partly  by  loss  of  the  compressing  and  sucking 
action  effected  by  winking,  partly  by  a  slight  falling  of  the 
lid  away  from  the  eye,  and  a  consequent  change  in  the 
position  of  the  punctum.  These  patients  sometimes  notice 
the  "  watery  eye  "  before  they  discover  the  other  symptoms. 
The  various  chronic  diseases  of  the  border  of  the  lids  (oph- 
thalmia tarsi),  and  also  granular  disease  of  the  conjunctiva 
(granular  lids),  are  fertile  sources  of  (1)  tumefaction  with 
narrowing  of  the  puncta  and  canaliculi;  (2)  cicatricial 


DISEASES    OF    LACHRYMAL    APPARATUS.       91 

stricture  of  the  same  parts ;  and  in  both  cases  the  puncta 
are  displaced  as  well  as  constricted.  Narrowing,  even  to 
complete  obliteration  of  the  puncta,  is  sometimes  seen  as 
the  result  of  former  inflammation,  of  which  all  traces  have 
long  since  passed  away.  Wounds  by  which  the  canaliculi 
are  cut  across  cause  their  obliteration,  and  epiphora  is  the 
result. 

In  all  the  above  cases  the  epiphora  is  accompanied  by  a 
visible  change  in  the  size  or  position  of  the  punctum,  none 
of  the  symptoms  of  inflammation  in  the  lachrymal  sac  or 
stricture  in  the  nasal  duct  being  present ;  and  simple  divis- 
ion of  the  canaliculus  will  cure  or  much  relieve  the  water- 
ing eye  (see  Operations).  This  measure  is,  however,  seldom 
necessary  in  the  epiphora  of  facial  paralysis. 

Epiphora  not  explained  by  any  of  the  above  changes  is 
in  most  cases  caused  by  obstruction  in  the  nasal  duct,  with 
or  without  disease  of  the  lachrymal  sac. 

Disease  of  the  sac  is  rarely  primary.  It  is  generally  due 
either  to  retention  of  secretion  caused  by  stricture  of  the 
duct  below,  or  to  the  mucous  membrane  participating  in  a 
chronic  inflammation  of  the  conjunctiva,  or  of  the  Schnei- 
derian  membrane. 

Obstruction  of  the  nasal  duct  is  usually  caused  by  chronic 
thickening  of  the  mucous  and  submucous  tissues  lining  the 
canal.  Dense,  hard  thickening  causes  a  stricture,  often 
very  tight  and  unyielding,  but  obstruction  is  common  with 
the  canal  of  full  size  or  even  dilated,  and  in  these  excess  of 
mucus  seems  to  be  the  chief  cause.  Disease  of  the  duct  is 
commonest  after  middle  life.  In  some  cases  the  change 
evidently  forms  a  part  of  a  chronic  disease  of  the  neighbor- 
ing mucous  membrane,  but  in  a  large  number  no  cause  can 
be  assigned.  Sometimes  stricture  is  the  result  of  periostitis 
or  of  necrosis,  and  of  these  conditions  syphilis  (either 
acquired  or  inherited),  scarlet  fever,  and  smallpox  are  the 


92      DISEASES    OF    LACHRYMAL    APPARATUS. 

commonest  causes.  Injuries  to  the  nose  account  for  a  few 
cases. 

A  stricture  may  be  seated  at  any  part  of  the  duct,  but 
the  upper  end,  where  there  is  often  a  natural  narrowing,  is 
the  commonest  spot. 

Obstruction  of  the  nasal  duct,  by  preventing  the  escape 
of  tears,  leads  to  distention  of  the  lachrymal  sac,  to  chronic 
thickening  of  its  lining  membrane,  and  increased  secretion 
of  mucus.  The  mucus  may  be  clear  or  turbid.  A  point 
is  reached  at  length  when  the  distention  can  be  seen  as  a 
little  swelling  under  the  skin  at  the  inner  canthus  (mucocele 
or  chronic  dacryo-cystitis).  This  swelling  can  generally  be 
dispersed  by  pressure  with  the  finger,  the  mucus  and  tears 
either  regurgitating  through  the  canaliculus  or  being  forced 
through  the  duct  down  into  the  nose.  In  cases  of  old  stand- 
ing the  sac  is  often  much  thickened,  and  may  contain 
polypi,  and  the  swelling  cannot  then  be  entirely  dispersed 
by  pressure. 

A  mucocele  is  always  very  apt  to  inflame  and  suppurate, 
the  result  being  a  lachrymal  abscess.  Most  cases  of  lachrymal 
abscess,  indeed,  have  been  preceded  by  mucocele.  Its 
formation  gives  rise  to  great  pain,  and  to  tense,  brawny, 
dusky  swelling,  which,  extending  for  a  considerable  dis- 
tance around  the  sac,  is  sometimes  mistaken  for  erysipelas. 
The  matter  always  points  a  little  below  the  tendo  palpe- 
brarum;  the  pus  often  burrows  in  front  of  the  sac,  forming 
little  pouches  in  the  cellular  tissue,  and  if  allowed  to  open 
spontaneously  a  fistula,  very  troublesome  to  cure,  is  likely 
to  follow.  If  seen  early,  before  there  is  decided  pointing, 
it  is  best  to  open  the  abscess  by  slitting  the  lower  canali- 
culus freely  into  the  sac,  and  passing  a  knife  down  the 
nasal  duct ;  anaesthesia  is  usually  necessary.  If  interfer- 
ence be  delayed,  the  skin  over  the  sac  soon  becomes  thinned, 
and  the  abscess  is  then  best  opened  through  the  skin  by  a 
free  puncture  inclined  downwards  and  a  little  outwards ; 


DISEASES    OF    LACHRYMAL    APPARATUS.       93 

no  anaesthetic  is  necessary,  and  the  resulting  scar  is  insig- 
nificant. When  the  thickening  has  subsided,  under  the 
use  of  warm  lead  lotion  dressing,  the  stricture  of  the  duct 
is  treated  ;  but  the  former  condition  of  mucocele  will  recur, 
and  another  abscess  may  form  at  any  time  unless  a  free 
passage  can  be  restored  down  the  nasal  duct. 

TREATMENT  OF  MUCOCELE  AND  LACHRYMAL  STRICT- 
URE.— The  object  aimed  at  is  the  permanent  dilatation  of 
the  stricture,  but  whether  this  can  be  gained  or  not  a  free 
opening  from  the  canaliculus  into  the  sac  should  be  main- 
tained, that  the  secretions  may  be  often  and  easily  squeezed 
out. 

Dilatation  by  probing  (see  Operations)  is  the  ordinary 
and  best  treatment  for  all  strictures,  whether  there  be 
mucocele  or  not,  the  rule  being  to  use  the  largest  probe  that 
will  pass  readily.  The  probing  is  repeated  every  few  days 
or  less  often,  according  to  the  duration  of  its  effect,  and 
often  needs  to  be  continued  for  weeks  or  months.  The  pa- 
tient may  sometimes  learn  to  use  the  probe  himself.  When 
the  stricture  is  tough  and  tight  it  is  best  at  once  to  divide 
it  by  thrusting  a  strong-backed,  narrow  knife  down  the 
duct,  and  afterwards  to  use  probes.  In  cases  where  the 
stricture  is  quite  soft,  and  the  obstruction  due  rather  to 
general  thickening  of  the  mucous  membrane  and  over- 
secretion  of  mucus  than  to  dense  fibrous  thickening,  the 
occasional  passage  of  a  very  large  probe,  or  frequent  wash- 
ing out  of  the  duct  with  water  or  weak  astringents  by 
means  of  a  lachrymal  syringe,  is  beneficial.  The  diligent 
and  long  use  of  astringent  lotions  to  the  conjunctiva  is  also 
useful  particularly  in  soft  strictures,  as  some  of  the  lotion 
reaches  the  sac  and  duct.  In  cases  of  long  standing,  where 
all  other  treatment  has  failed  and  the  lachrymal  sac  is  much 
thickened,  its  complete  obliteration  by  the  actual  cautery 
gives  great  relief;  extirpation  of  the  lachrymal  gland  is  also 
occasionally  practised.  For  refractory  children  and  for 


94      DISEASES    OF   LACHRYMAL   APPARATUS. 

patients  who  cannot  be  seen  often,  a  style  of  silver  or  lead, 
passed  in  exactly  the  same  way  as  a  probe,  but  worn  con- 
stantly for  many  weeks,  is  sometimes  very  useful ;  but  it 
may  slip  into  the  sac  out  of  reach  unless  furnished  with  a 
bend  or  head  so  large  as  to  be  somewhat  unsightly.  As  a 
rule,  probing  is  not  to  be  begun  until  the  inflammatory 
thickening  and  tenderness  following  a  lachrymal  abscess 
have  subsided.  It  must  be  confessed,  however,  that  in  a 
considerable  proportion  of  lachrymal  cases,  whether  the 
stricture  be  soft  or  firm,  the  final  results  of  all  treatment 
are  but  palliative,  and  that  the  benefit  obtained  is  not  always 
worth  the  pain  and  inconvenience. 

Suppuration  of  the  lachrymal  sac,  on  one  or  both  sides, 
sometimes  takes  place  in  new-born  infants  without  apparent 
cause ;  if  there  be  much  redness,  the  abscess  should  be 
opened,  but  the  suppuration  is  sometimes  chronic,  and  will 
cease  under  the  use  of  astringent  lotions.  The  cases  of 
epiphora  with  contracted  punctum,  which  are  sometimes 
met  with  in  older  children,  may  perhaps  be  the  conse- 
quences of  this  infantile  suppuration. 

Cases  in  which  the  sac  or  duct  is  obliterated  by  injury 
can  seldom  be  relieved. 


DISEASES     OF     THE     CONJUNCTIVA.  95 


CHAPTER   VII. 

DISEASES    OF   THE    CONJUNCTIVA 

MAY  be  divided  into  those  which  from  the  outset  are 
general  and  affect  the  whole  membrane,  ocular  and  palpe- 
bral  alike,  and  of  which  the  various  forms  01  contagious 
ophthalmia  are  examples ;  and  those  which  primarily  affect 
either  the  ocular  or  the  palpebral  part  alone.  The  term 
"ophthalmia"  includes  all  inflammations  of  the  conjunctiva, 
and  should  not  be  applied  to  any  other  diseases. 

GENERAL  DISEASES. 

The  conjunctiva,  like  the  urethra,  is  subject  to  purulent 
inflammation,  and,  like  the  respiratory  mucous  membrane, 
is  liable  to  the  muco-purulent  and  to  the  membranous  or 
diphtheritic  forms  of  disease.  All  cases  in  which  there  is 
yellow  discharge  are  in  greater  or  less  degree  contagious. 
The  congestion,  which  forms  a  part  of  conjunctivitis,  is 
much  influenced  by  age ;  the  younger  the  patient  the  less 
is  the  congestion  in  proportion  to  the  discharge,  a  fact  to 
be  borne  in  mind  in  examining  patients  at  both  ends  of  the 
scale. 

Purulent  ophthalmia  (O.  neonatorum,  Gonorrhoeal  O., 
Blennorrhrea  of  the  conjunctiva)  is  generally  due  to  con- 
tagion from  the  same  disease,  or  from  an  acute  or  chronic 
discharge  from  the  urethra  or  vagina,  whether  gonorrhceal 
or  not.  Muco-purulent  ophthalmia  when  quickly  passed 
on  from  one  to  another  under  conditions  of  health  favorable 
to  suppuration  (e.  g.,  weakness  after  acute  exanthems)  may 
be  intensified  into  the  purulent  form.  Gonorrhoea  has  been 


96  DISEASES     OF     THE     CONJUNCTIVA. 

experimentally  produced  by  inoculation  with  pus  from 
purulent  ophthalmia.  Some  animals  are  subject  to  puru- 
lent ophthalmia,  but  it  is  said  that  the  discharge  from  the 
human  disease,  and  even  from  gonorrhoea,  gives  no  result 
on  the  conjunctiva  of  rabbits.  Like  gonorrhrea,  purulent 
ophthalmia  may  occur  more  than  once.  It  varies  greatly 
in  severity,  but  is,  on  the  whole,  much  milder  in  babies 
than  in  older  persons.  The  quality  of  the  infecting  dis- 
charge no  doubt  has  much  influence,  severe  forms  being 
generally  caused  by  inoculation  from  a  recent  or  severe 
case ;  but  chronic  discharge  may  also  give  rise  to  a  severe 
attack.  The  health  of  the  recipient  and  the  previous  con- 
dition of  the  eyelids  exert  an  important  influence ;  if  the 
lids  be  granular,  various  slight  causes  sometimes  bring  on 
severe  purulent  ophthalmia. 

The  disease  sets  in  from  twelve  to  about  forty-eight  hours 
after  inoculation ;  in  infants  the  third  day  after  birth  is  al- 
most invariably  given  as  the  date  when  discharge  was  first 
noticed.  Itchiness  and  slight  redness  of  conjunctiva  soon 
pass  on  to  intense  congestion  of  conjunctiva  with  chemosis, 
tense  inflammatory  swelling  of  the  lids,  great  pain,  and 
discharge.  The  discharge  at  first  is  serous,  or  like  turbid 
whey,  but  soon  becomes  more  profuse,  creamy  (purulent), 
and  yellow,  or  even  slightly  greenish.  Dark,  abrupt  ecchy- 
moses  are  often  present.  The  lids,  always  swollen,  hot  and 
red,  in  bad  cases  become  very  tense  and  dusky.  The  upper 
lid  hangs  down  over  the  lower,  and  is  often  so  stiff  that  it 
cannot  be  completely  everted.  The  conjunctiva  is  succu- 
lent, and  easily  bleeds. 

The  disease,  if  untreated,  declines  spontaneously,  and 
the  discharge  almost  ceases  in  about  six  weeks,  the  palpe- 
bral  conjunctiva  being  left  thick,  relaxed,  and  more  or  less 
granular.  Cicatricial  changes,  identical  with,  but  less  se- 
vere than,  those  resulting  from  chronic  granular  lids,  and 
analogous  to  what  occurs  in  stricture  of  the  urethra,  some- 


DISEASES     OF     THE     CONJUNCTIVA.  97 

times  follow;  considerable  permanent  thickening  of  the 
ocular  conjunctiva  may  also  occur. 

There  is  a  great  risk  to  the  cornea  in  this  disease,  partly 
from  strangulation  of  the  vessels,  partly  from  the  local  influ- 
ence of  the  discharge.  If  within  the  first  two  or  three  days 
the  cornea  becomes  hazy  and  dull,  like  that  of  a  dead  fish, 
there  is  great  risk  that  total  or  extensive  sloughing  will  occur. 
In  milder  cases,  ulcers,  often  transparent,  frequently  form 
near  the  margin,  and  rapidly  cause  perforation.  In  many 
of  the  slighter  cases,  such  as  are  seen  in  infants,  no  corneal 
damage  occurs.  Either  one  or  both  eyes  may  be  attacked ; 
in  adults  one  eye  often  escapes ;  in  infants,  where  the  inocu- 
lation occurs  during  birth,  both  eyes  almost  always  suffer. 

TREATMENT. — If  oaly  one  eye  be  affected,  and  the  patient 
be  old  enough  to  obey  orders,  the  sound  eye  must  be  cov- 
ered up  with  the  shield  introduced  by  Dr.  Buller;  take  two 
pieces  of  India-rubber  plaster,  one  4i ",  the  other  4"  square ; 
cut  a  round  window  in  the  middle  of  each,  and  stick  them 
together,  with  a  small  watch-glass  inserted  into  the  window. 
The  plaster  is  fixed  by  its  free  border  and  by  other  strips 
to  the  nose,  forehead,  and  cheek,  and  the  patient  looks 
through  the  glass ;  the  lower  outer  angle  is  left  open  for 
ventilation ;  particular  attention  is  to  be  paid  to  the  fasten- 
ing on  the  nose.  All  concerned  are  to  be  warned  as  to  the 
risk  of  contagion  and  the  means  of  conveying  it.  The  es- 
sential curative  measures  are :  (1)  Frequent  removal  of 
the  discharge  by  the  free  use  of  water.  Every  hour,  day 
and  night,  or  in  adults  every  two  hours,  the  lids  are  gently 
opened  and  the  discharge  removed  with  soft  bits  of  moist- 
ened rag  or  cotton  wool ;  or  a  syringe  or  irrigation  appa- 
ratus may  be  used.  In  adults,  where  the  swelling  is  often 
extreme  and  very  brawny,  we  may  increase  the  congestion 
and  irritability  by  interfering  oftener  than  every  two  hours. 
(2)  The  frequent  anointing  of  the  lids  with  a  simple  oint- 
ment. (3)  The  use  of  astringent  or  antiseptic  lotions  once 

9 


98  DISEASES     OF     THE     CONJUNCTIVA. 

ail  hour,  or  every  two  or  three  hours,  according  to  the  case 
and  the  nature  and  strength  of  the  solution.  The  lotion 
may  be  alum  (eight  or  ten  grains  to  the  ounce),  or  sulphate 
of  zinc  and  alum,  used  very  freely  every  hour  or  two;  or 
corrosive  sublimate  (one-eighth  or  one-quarter  of  a  grain) ; 
or  chloride  of  zinc  (two  grains,  with  just  enough  dilute  hy- 
drochloric acid  to  make  a  clear  solution),  used  freely  every 
two  or  three  hours;  or  pure  carbolic  acid,  5  per  cent.,  every 
hour;  or  nitrate  of  silver  (two  grains),  four  or  six  times  a 
day.  Many  surgeons  greatly  prefer  the  last  to  all  others. 
(4)  Strong  solutions  of  nitrate  of  silver,  or  the  mitigated 
solid  nitrate  (F.  1  and  2),  are  of  great  service  in  shortening 
the  attack  and  lessening  the  risks,  and  should  be  used  in 
all  severe  cases  unless  specially  contraindicated.  A  ten-  or 
twenty -grain  solution  is  brushed  freely  over  the  conjunctiva 
of  the  lids  everted  as  well  as  possible,  and  freed  from  dis- 
charge. If  the  mitigated  stick  is  used,  more  care  is  needed ; 
and,  to  prevent  too  great  ail  effect,  it  is  to  be  washed  off 
with  water  after  waiting  about  fifteen  seconds.  These 
strong  applications  must  be  made  by  the  surgeon;  the 
pain  caused  by  them  is  lessened  and  the  beneficial  effect 
increased  by  free  bathing  with  cold  or  iced  water  after- 
wards. The  application  is  not  to  be  repeated  until  the 
discharge,  which  will  be  »arkedly  lessened  for  some  hours, 
has  begun  to  increase  again ;  it  is  seldom  needful  or  justi- 
fiable more  than  once  a  day.  (5)  Local  cold  by  iced  water 
or  thin  ice  compresses ;  in  severe  cases  to  be  used  almost 
constantly,  in  milder  cases  frequently  for  periods  of  half  an 
hour.  This  plan,  but  little  adopted  in  our  hospital  prac- 
tice, is  very  highly  spoken  of  as  most  efficacious,  if  begun 
early  and  carried  out  well ;  but  if  only  half  done,  it  is  use- 
less and  disagreeable.  Hot  fomentations  are  sometimes 
better  than  cold.  (6)  In  the  early  stage,  in  adults,  several 
leeches  to  the  temple  will  give  relief;  or,  if  the  swelling  be 
very  tense,  we  may  divide  the  outer  canthus  with  scissors 


DISEASES     OF     THE     CONJUNCTIVA.  99 

or  knife,  and  thus  botli  bleed  and  relax  the  parts  at  the 
same  time.  Scarification  of  the  palpebral  conjunctiva  and 
radial  incisions  in  the  ocular  conjunctiva  may  be  tried. 
Mr.  Critchett  has,  in  very  bad  cases,  gone  so  far  as  to  di- 
vide the  upper  lid  vertically  across,  and  keep  its  two 
halves  turned  upwards  by  means  of  sutures  fastened  to  the 
forehead. 

The  following  additional  precautions  are  important : 
Strong  nitrate  of  silver  applications  are  unsafe  in  the  ear- 
liest stage,  before  free  discharge  has  set  in,  and  also  in  cases 
where,  even  later  in  the  disease,  there  is  much  hard,  brawny 
swelling  of  the  ocular  conjunctiva,  and  comparatively  little 
discharge ;  cases,  in  fact,  approaching  the  condition  known 
as  diphtheritic  ophthalmia.  In  these,  either  very  cold  or 
very  hot  applications,  leeches,  cleanliness,  and  weak  lotions 
should  be  chiefly  relied  upon.  Ice  and  leeches  are  seldom 
advisable  for  infants.  It  is  of  extreme  importance  to  begin 
treatment  very  early,  for  the  cornea  is  often  irreparably 
damaged  within  two  or  three  days.  The  patients,  if  adults, 
are  often  in  feeble  health,  and  need  supporting  treatment. 
Ulceration  of  the  cornea  does  not  contraindicate  the  use  of 
strong  nitrate  of  silver  if  the  discharge  is  abundant.  Treat- 
ment must  be  continued  so  long  as  there  is  any  discharge, 
or  the  conjunctiva  of  the  lids  remains  fleshy,  for  a  relapse 
of  purulent  discharge  often  takes  place  if  remedies  are  dis- 
continued too  soon. 

Muco-purulent  ophthalmia. — The  commonest  and  best 
characterized  of  the  acute  ophthalmias  is  the  so-called 
catarrhal  ophthalmia.  The  name  is  a  bad  one,  for  neither 
does  the  disease  form  part  of  a  general  catarrh  of  the  re- 
spiratory tract,  nor  does  it  show  the  tendency  to  relapse  so 
characteristic  of  catarrh,  nor  does  it  seem  to  be  caused  by 
cold.  The  disease  attains  its  height  very  quickly,  almost 
always  attacks  both  eyes,  and  gets  well  spontaneously  in 
about  a  fortnight.  There  is  great  congestion,  much  gritty 


100          DISEASES     OF     THE     CONJUNCTIVA. 

pain,  which  often  prevents  sleep,  spasm  of  the  lids,  free, 
muco-purulent  discharge,  and,  in  many  cases,  ecchymotic 
or  thrombotic  patches  in  the  conjunctiva.  The  lids  are 
somewhat  swollen  and  red,  but  never  tense,  and  the  cornea 
seldom  suffers. 

This  disease  is  apparently  far  more  contagious  than  pur- 
ulent ophthalmia,  for  which  it  is  sometimes  mistaken.  It 
varies  much  in  severity,  even  in  different  members  of  the 
same  household,  who  catch  it  almost  at  the  same  time,  but 
attacks  all  ages  indiscriminately.  It  is,  I  believe,  common- 
est in  warm  weather,  or  perhaps  at  the  change  from  cold 
to  warm.  It  is  rare  to  find  that  the  patient  has  suffered 
from  the  disease  before.  Any  mild  astringent  lotion  will 
cut  it  short. 

Troublesome  ophthalmia,  ivith  muco-purulent  discharge,  is 
common  in  children  after  exanthemata,  especially  measles. 
It  runs  a  less  definite  course  than  the  preceding  disease, 
shows  but  little  tendency  to  spontaneous  cure,  rifed  «s  very 
often  complicated  with  phlyctenular  ulcers  of  the  cornea, 
blepharitis,  and  eruptions  on  the  face;  and  the  patients  are 
frequently  strumous.  The  discharge  is  seldom  so  abundant 
as  in  the  disease  just  considered.  The  treatment  is  often 
troublesome,  and  many  changes  have  to  be  tried ;  weak 
nitrate  of  silver  lotions  (F.  3),  with  the  use  of  yellow  oint- 
ment (F.  10),  or  boracic  acid  ointment,  both  to  the  skin 
and  conjunctiva,  or  calomel  dusted  into  the  eye,  are  the 
best  local  means;  atropine  often  increases  the  irritation. 
Careful  attention  to  health  is  necessary.  The  patient 
should  not  be  confined  to  the  house,  but,  with  a  large 
shade  over  both  eyes,  should  take  plenty  of  exercise  in  fine 
weather.  The  eyes  should  not  be  bandaged  in  any  form  of 
ophthalmia;  and  poultices  are  very  seldom  suitable. 

Some  forms  of  acute  conjunctivitis,  with  little  or  no  dis- 
charge, are  seen  both  in  children  and  adults,  which  do  not 
conform  to  the  above  types,  and  are  of  comparatively  slight 


DISEASES     OF     THE     CONJUNCTIVA.  101 

importance.  Many  such  appear  to  depend  on  changes  of 
weather  or  exposure  to  cold,  and  are  complicated  with 
phlyctenulse.  A  few  are  distinctly  rheumatic.  The  con- 
junctiva is  involved  more  or  less  in  herpes  zoster  of  the 
ophthalmic  division  of  the  fifth  nerve,  in  erysipelas  of  the 
face,  in  the  early  stage  of  measles,  and  slightly  in  eczema 
of  the  face.  Slight  degrees  of  chronic  conjunctivitis  are 
set  up  by  various  local  irritants,  dust,  smoke,  cold  wind, 
etc.,  and  by  the  strain  attending  the  use  of  the  eyes  without 
glasses  in  cases  of  hypermetropia.  Mention  must  be  made 
of  the  not  very  common  cases  in  children,  where  an  oph- 
thalmia appears  to  form  part  of  an  irnpetiginous  or  herpetic 
eruption  on  the  face,  with  which  it  is  simultaneous.  These 
differ  from  the  ordinary  instances  in  which  the  lids,  cheek, 
and  lining  membrane  of  the  nose  are  irritated  into  an 
eruption  by  tears  and  discharge  from  a  pre-existing  con- 
junctivitis. 

Muco-purulent  ophthalmia,  of  any  kind,  becomes  a  very 
important  affair  if  it  breaks  out  in  schools  or  armies,  etc., 
where  granular  disease  of  the  eyelids  is  prevalent  (p.  105). 

Membranous  and  diphtheritic  ophthalmia. — In  a  few 
cases  of  ophthalmia,  either  purulent  or  muco-purulent,  the 
discharge  adheres  to  the  conjunctiva  in  the  form  of  a  mem- 
brane (membranous  or  croupoiis  ophthalmia).  Still  more 
rarely,  in  addition  to  the  membrane  on  the  surface,  the 
whole  depth  of  the  conjunctiva  is  stiffened  by  solid  exuda- 
tion, which  much  impairs  the  mobility  of  both  the  lids  and 
eyeball,  and,  by  compressing  the  vessels,  prevents  the 
formation  of  free  discharge,  and  places  the  nutrition  of  the 
cornea  in  great  peril.  It  is  to  the  latter  cases  that  the  term 
diphtheritic  is  limited  by  most  authors ;  but  we  find  many 
connecting  links  between  the  two  types  above  defined,  and 
between  each  of  them  and  the  ordinary  purulent  and  muco- 
purulent  cases. 

It  is  of  much  consequence  in  practice,  both  for  prognosis 


102          DISEASES     OF     THE     CONJUNCTIVA. 

and  treatment,  to  recognize  the  presence  of  membranous 
discharge  and  of  solid  infiltration,  in  any  case  of  ophthal- 
mia; for  the  liability  to  severe  corneal  damage  is  much 
increased  by  both  these  conditions,  and  especially  by  the 
latter.  When  membrane  is  present,  it  may  cover  the  whole 
inside  of  the  lids,  or  it  may  occur  in  separate  or  in  conflu- 
ent patches ;  it  often  begins  at  the  border  of  the  lid,  and  is 
seldom  found  on  the  ocular  conjunctiva.  It  can  be  peeled 
off,  and  the  conjunctiva  beneath  bleeds  freely,  unless  infil- 
trated and  solid ;  in  the  latter  case  the  membrane  is  more 
adherent,  the  conjunctiva  is  of  a  palish  color,  and  scarcely 
bleeds  when  exposed,  and  there  is  little  or  no  purulent  dis- 
charge. In  most  cases  the  solid  products,  whether  mem- 
brane or  deep  infiltration,  pass  after  some  days  into  a  stage 
of  liquefaction,  with  free  purulent  secretion.  In  rare  cases 
the  membrane  forms  and  re-forms  for  months.  As  regards 
cause,  (1)  very  rarely  the  process  creeps  up  to  the  conjunc- 
tiva from  the  nose  in  cases  of  primary  diphtheria,  or  is 
caused  by  inoculation  of  the  conjunctiva  with  membrane; 
Avhilst  in  a  few  the  ophthalmia  forms  the  first  symptom 
of  general  diphtheria,  or  of  masked  or  anomalous  scarlet 
fever.  (2)  Much  more  commonly  it  is  part  of  a  diphtheritic 
type  of  inflammation  following  some  acute  illness.  (3)  It 
may  be  caused  by  the  over-use  of  caustics  in  ordinary  puru- 
lent ophthalmia  (p.  99).  (4)  It  may  be  due  to  contagion, 
either  from  a  similar  case  or  from  a  purulent  ophthalmia, 
or  a  gonorrhea,  the  membranous  or  diphtheritic  type  de- 
pending on  some  peculiarity  in  the  health  or  tissues  of  the 
recipient.  Membranous  and  diphtheritic  ophthalmia  are 
seen  most  often  in  children  from  two  to  eight  years  old, 
sometimes  in  young  infants,  and  less  commonly  in  adults. 
It  is  commoner  in  North  Germany  than  in  other  parts  of 
Europe,  but  very  severe  and  even  fatal  cases  occur  in  our 
own  country. 

In  treatment  the  cardinal  point  is  not  to  use  nitrate  of 


DISEASES     OF     THE     CONJUNCTIVA.  103 

silver  in  any  form  when  there  is  scanty  discharge  and  much 
solid  infiltration  of  the  conjunctiva.  The  agents  to  be  re- 
lied upon  are  (1)  either  ice  or  hot  fomentations;  ice,  if  it 
can  be  used  continuously  and  well ;  fomentations,  to  encour- 
age liquid  exudation  and  determination  to  the  skin  if  the 
cold  treatment  cannot  be  carried  out,  or  fails  to  make  any 
impression  on  the  case ;  (2)  leeches,  if  the  patient's  state 
will  bear  them ;  (3)  great  cleanliness.  The  presence  of 
membrane  is  no  bar  to  the  use  of  caustics,  provided  that 
the  conjunctiva  is  succulent,  red,  and  bleeds  easily.  Mr. 
Tweedy  strongly  advises  quinine  lotion  used  very  frequently 
(F.  21). 

The  local  use  of  atropine  sometimes  gives  rise  to  a  pecu- 
liar inflammation  of  the  conjunctiva  and  skin  of  the  lids — 
"atropine  irritation."  The  conjunctiva  of  the  lids  becomes 
vascular,  thickened,  and  even  granular,  the  skin  reddened, 
slightly  excoriated,  somewhat  shining,  but  lax.  This  effect 
of  atropine  is  commonest  in  old  people.  Some  persons  are 
very  susceptible  and  cannot  bear  even  a  drop  or  two  with- 
out suffering  in  some  degree.  Daturine  and  duboisiu  cause 
less  irritation  and  may  be  used  instead,  unless  it  be  safe  to 
disuse  all  mydriatics  for  a  few  days.  An  ointment  con- 
taining some  lead  and  zinc  should  be  applied  to  the  lids, 
and  zinc  or  silver  lotion  to  the  conjunctiva;  in  other  cases 
glycerine  to  the  skin  suits  better  than  ointment.  Eserine 
sometimes  causes  identical  symptoms.  This  condition  is 
said  to  be  prevented  by  adding  a  very  little  carbolic  acid 
(.  1  per  cent.)  to  the  solutions. 

Granular  ophthalmia  (trachoma)  is  a  very  important 
malady,  characterized  by  slowly  progressive  changes  in  the 
conjunctiva  of  the  eyelids,  in  consequence  of  which  this 
membrane  becomes  thickened,  vascular,  and  roughened  by 
firm  elevations,  instead  of  being  pale,  thin,  and  smooth. 
The  change  usually  begins  in  the  follicular  structures  of 
the  conjunctiva  of  the  lower  lid,  extending  to  the  papilla? 


104  DISEASES     OF     THE     CONJUNCTIVA. 

and  the  submucous  tissue  of  both  lids  at  a  later  period,  and 
giving  rise  to  the  growth  of  much  organized  new  tissue  in 
the  deep  parts  of  the  conjunctiva.  This  tissue  is  afterwards 
partly  absorbed  and  partly  converted  into  a  dense  tendinous 
scar,  which  by  very  slow  shrinking  often  gives  rise  to  much 
trouble.  It  is  important  to  remember  that  the  conjunctiva 
in  this  disease  does  not  ulcerate,  and  that  the  prominences 
are  not  "granulations"  in  the  pathological  sense. 

The  disease  is  first  shown  by  the  presence  on  the  lower 
lid  of  a  number  of  rounded,  pale,  semi-transparent  bodies 
like  little  grains  of  boiled  sago,  or  sometimes  looking  like 
vesicles;  the  so-called  "vesicular,"  or  "sago-grain,"  or 
"follicular"  granulations  (Fig.  35).  Some  of  these  appear 

Pie.  35. 


Granular  lower  lid  (after  Eble). 

to  be  lymphatic,  others  tubular  mucous  follicles.  They 
are,  to  a  certain  degree,  normal,  and  are  seen,  especially  on 
the  lower  lids,  in  many  young  persons  with  slight  ophthal- 
mia who  never  afterwards  suffer  from  true  granular  lids. 
Such  mild  cases  in  which  no  parts  deeper  than  the  follicles 
and  papillae  are  affected,  and  in  which  recovery  takes  place 
without  cicatricial  changes,  are  by  some  distinguished 
authors  placed,  under  the  name  of  conjunctivitis  follicularis, 
in  a  separate  category  from  the  granular  disease.  The 
latter  disease  is  held  on  this  hypothesis  to  depend  on  a 
different  morbid  process,  th'e  growths  or  "granulations" 
bearing  no  relation  to  lymph-follicles.  But  the  frequent 
coincidence  of  transition  forms  in  the  same  case,  the  fact 


DISEASES     OF     THE    CONJUNCTIVA.  105 

that  both  follicular  conjunctivitis  and  well-marked  granular 
disease  admittedly  occur  under  the  same  general  conditions, 
and  that  in  a  given  case  the  distinctions  between  "  follicles  " 
and  "  granulations  "  often  cannot  be  made  until  it  is  known 
whether  or  not  cicatricial  changes  will  occur,  certainly 
much  lessen  the  clinical  value  of  the  asserted  pathological 
difference. 

Granular  disease  is  very  important  because  it  greatly  in- 
creases the  susceptibility  of  the  conjunctiva  to  take  on  acute 
inflammation  and  to  produce  contagious  discharge,  makes 
it  less  amenable  to  treatment,  and  very  liable  to  relapses  of 
ophthalmia  for  many  years,  and  often  gives  rise  to  deform- 
ities of  the  lid  and  to  serious  damage  of  the  cornea.  So 
vulnerable  is  the  granular  conjunctiva  that  it  is  rare  in 
ordinary  practice  to  see  granular  lids  of  long  standing 
without  the  history  of  an  acute  ophthalmia  at  some  pre- 
vious time,  though  many  such  may  be  seen  in  crowded 
schools,  etc. 

Chronic  granular  disease  is  the  result  (1)  of  prolonged 
overcrowding,  or  rather  of  long  residence  in  badly  venti- 
lated and  damp  rooms  ;  it  used  to  be  very  abundant  in  the 
army  and  navy,  and  is  still  seen  in  great  perfection  in 
workhouse  schools ;  (2)  a  generally  low  state  of  health,  no 
doubt,  increases  the  susceptibility  to  it ;  (3)  it  is,  ccderis 
paribus,  commonest  and  most  quickly  produced  in  children ; 
(4)  certain  races  are  peculiarly  liable  to  suffer,  e.  g.,  the 
Irish,  the  Jews,  and  some  other  Eastern  races,  and  some 
of  the  German  and  French  races.  The  Irish  and  Jews 
carry  it  with  them  all  over  the  world,  and  transmit  the 
liability  to  their  descendants  wherever  they  live.  Negroes 
in  America  are  said  to  be  almost  exempt ;  (5)  damp  and 
low-lying  climates  are  more  productive  of  it  than  others ; 
thus  it  is  rare  in  Switzerland.  Possibly  what  are  now  race 
tendencies  may  be  the  expression  of  climatal  conditions 
acting  on  the  same  race  through  many  generations.  When 


DISEASES     OF     THE     CONJUNCTIVA. 

accompanied  by  discharge  the  disease  is  contagious,  but  not 
otherwise ;  and  it  is  generally  held  that  the  discharge  from 
a  case  of  trachoma  is  specific,  i.  e.,  that  it  will  give  rise  by 
contagion,  not  only  to  muco-purulent  or  purulent  ophthal- 
mia, but  to  the  true  granular  disease.  This  point  is  a  very 
difficult  one  to  decide,  but  my  own  experience  inclines  me 
to  accept  the  view,  at  least  for  some  cases. 

Those  who  practise  in  the  army,  or  who  have  charge  of 
such  institutions  as  pauper  schools,  will  find  that  in  prac- 
tice the  causes  of  the  chronic  granular  condition  are  inex- 
tricably mixed  up  with  all  kinds  of  facilities  for  contagion, 
and  that  it  will  be  necessary  to  fight  against  two  enemies 
— the  causes  of  spontaneous  granular  disease,  and  the 
sources  of  contagious  discharge.  The  former  is  to  be  com- 
bated by  improved  hygienic  conditions,  especially  by  free 
ventilation,  dry  air,  abundant  open-air  exercise,  and  im- 
provement of  the  general  vigor.  The  sources  of  contagion 
are  endless,  especially  since,  as  has  been  stated,  granular 
patients  are  liable  to  relapses  of  muco-purulent  discharge 
from  almost  any  slight  irritation.  Frequent  inspection  of 
all  the  eyes,  rigid  separation  of  all  who  show  any  discharge 
or  are  known  as  especially  subject  to  relapses;  such  arrange- 
ments for  washing  as  will  prevent  the  use  of  towels  and 
water  in  common,  extreme  care  against  the  introduction  of 
contagious  cases  from  without — such  are  the  chief  pre- 
ventive measures.  Extra  precautions  will  be  needed  in 
time  of  war  or  famine,  or  when  measles  or  scarlet  fever  are 
prevalent,  or  during  marches  through  hot,  sandy,  or  windy 
districts. 

The  curative  treatment,  when  discharge  is  present,  does 
not  differ  from  that  of  the  acute  ophthalmias  already  given. 
The  use  of  strong  astringents  (solid  sulphate  of  copper)  or 
caustics  (nitrate  of  silver  in  strong  solution,  or  in  the  miti- 
gated solid  pencil),  however,  is  generally  needed  in  order 
to  make  much  impression  on  the  granular  state  of  the  lids. 


DISEASES     OF    THE     CONJUNCTIVA.          107 

The  lids,  being  thoroughly  everted,  are  touched  all  over 
with  one  or  other  application,  and  this  is  repeated  daily, 
or  less  often,  according  to  the  case.  Some  practice  is  re- 
quired before  we  can  decide  on  the  needful  frequency  for 
each  case.  By  careful  treatment  on  this  principle,  most 
patients  may  be  kept  comfortably  free  from  active  symp- 
toms, many  relapses  may  be  prevented,  the  duration  of  the 
disease  shortened,  and  the  risks  of  secondary  damage  to  the 
cornea  much  lessened.  Do  what  we  will,  however,  granu- 
lar disease,  when  well  established,  is  most  tedious,  and  fas- 
tens many  risks  and  disabilities  on  its  subjects  for  years  to 
come. 

For  routine  treatment  on  a  large  scale,  nothing  is  so 
effectual  as  nitrate  of  silver,  either  a  ten-  or  twenty-grain 
solution,  or  the  mitigated  solid  point  (F.  1  and  2).  But 
silver  has  the  disadvantage  of  sometimes  permanently 
staining  the  conjunctiva  after  long  use,  and  in  very  chronic 
cases  I  think  either  sulphate  of  copper  or  the  lapis  divinus 
(F.  5)  is  to  be  preferred,  especially  as  the  patient  may 
sometimes  be  taught  to  evert  his  own  lids  and  use  it  him- 
self. The  solid  mitigated  nitrate  of  silver  needs  washing 
off  with  water  at  first  (p.  98),  but  in  old  cases  it  is  often 
better  not  to  do  so. 

Results  of  granular  disease. — Friction  by  the  granula- 
lations  of  the  upper  lid  (a,  Fig.  36),  especially  in  cases  of 

FIG.  36. 


Granular  upper  lid,  with  scarring. 

long  standing  where  some  scarring  is  present  (&),  often 
causes  cloudiness  of  the  cornea,  partly  from  ulceration,  but 


108  DISEASES     OF     THE     CONJUNCTIVA. 

mainly  from  the  growth  of  a  layer  of  new  and  very  vascu- 
lar tissue,  just  beneath  the  epithelium  (pannus)  (Fig.  37). 
In  later  periods  the  conjunctiva  and  deeper  tissues  are 
shortened  and  puckered  by  the  scar  following  absorption 
of  the  "granulations."  These  changes,  when  severe,  often 
lead  to  inversion  of  the  border  of  the  lid  (entropion*)  ;  when 

FIG.  37. 

Ept. 

'Scl. 


Section  showing  layer  of  new  and  vascular  tissue  (pannus)  between 
epithelium  (Ept.)  and  cornea  ((7.).  Scl.  sclerotic  ;  CM.  ciliary  muscle; 
Sch.  C.  Schlemm's  canal;  /.  iris.  X  about  10  diameters. 

slighter,  some  or  all  of  the  lashes  may  be  distorted  so  as  to 
rub  against  the  cornea,  without  actually  turning  inwards 
(distichiasis,  trichiasis)  ;  and  these  conditions  are  often 
combined  with  pannus.  Pannus  begins  beneath  the  upper 
lid,  its  vessels  are  superficial  and  continuous  with  those  of 
the  conjunctiva,  and  are  distributed  in  relation  to  the  parts 
covered  by  the  lid,  not  in  reference  to  the  structure  of  the 
cornea  (Fig.  38).  The  proper  corneal  tissue  suffers  but  little 
except  where  ulcers  occur;  but  when  the  vascularity  is 
extreme,  it  may  soften  and  bulge  even  without  ulcerating. 
Pannus  disappears  when  the  granular  lid,  or  the  dis- 
placement of  lashes,  is  cured.  Very  severe  and  universal 
pannus  is  sometimes  best  treated  by  artificial  inoculation 
with  purulent  ophthalmia,  the  inflammation  being  followed 
by  obliteration  of  vessels  and  clearing  of  the  cornea  ;  but 
this  treatment  needs  great  judgment  and  caution.  Removal 
of  a  zone  of  conjunctiva  and  subconjunctival  tissue  (syn- 
dectomy,  peritomy}  from  around  the  cornea  is  free  from  risk 
and  sometimes  very  beneficial  in  old  cases  which,  though 


DISEASES     OF     THE    CONJUNCTIVA.  109 

severe,  are  not  bad  enough  for  inoculation.  In  old  cases 
of  granular  disease,  even  where  no  complications  have 
arisen,  the  upper  lids  often  droop  from  relaxation  of  the 


FIG.  38. 


Pannus  affecting  upper  half  of  cornea. 

loose  conjunctiva  above  the  tarsal  cartilage,  and  the  patient 
acquires  a  sleepy  look. 

For  the  cure  of  the  displaced  lashes  and  incurved  eyelid 
we  may — (1)  repeatedly  pull  out  the  lashes  with  forceps ; 
(2)  extirpate  all  the  lashes  by  cutting  out  a  narrow  strip 
of  the  marginal  tissues  of  the  lid ;  or  (3)  attempt  by  opera- 
tion to  restore  the  parts  to  their  proper  positions  (see  Ope- 
rations). These  operations  for  restoring  the  lashes  to  their 
normal  direction  often  give  only  temporary  relief,  chiefly 
because  the  inner  surface  of  the  lid  continues  to  shorten, 
and  thus  the  original  state  of  things  is  sooner  or  later 
reproduced. 

Chronic  conjunctivitis,  chiefly  of  the  lower  lid,  is  a  com- 
mon disease,  especially  in  elderly  people.  There  is  more 
or  less  soreness  and  smarting,  a  very  little  discharge,  red- 
ness and  papillary  roughness  of  the  inner  surface  of  the  lid 
or  of  both  lids,  but  no  true  trachoma  granulations.  The 
caruncle  is  red  and  fleshy,  as  it  is  in  all  forms  of  palpebral 
conjunctivitis,  and  there  is  often  soreness  of  the  lids  at  the 
canthi.  Lapis  divinus  is  one  of  the  best  applications,  and 
yellow  ointment  is  sometimes  useful  (F.  5  and  10). 

10 


110  DISEASES     OF    TI1E     COKNEA, 


CHAPTER   VIII. 

DISEASES    OF    THE    CORNEA. 

A.  ULCERS  AND  NON-SPECIFIC  INFLAMMATORY  DISEASES. 

INFLAMMATION  of  the  cornea  may  be  circumscribed  or 
diffuse,  and,  though  usually  affecting  the  proper  corneal 
tissue,  may  be  limited  to  the  epithelium  on  either  of  its 
surfaces.  It  may  be  a  local  process  leading  to  formation  of 
pus,  or  to  ulceration ;  or  the  expression  of  a  constitutional 
disease,  such  as  inherited  syphilis ;  or  it  may  form  part, 
and  perhaps  only  a  minor  part,  of  disease  involving  also 
the  deeper  parts  of  the  eyeball — the  iris  (kerato-iritis),  or 
sclerotic  (sclero-keratitis),  for  example. 

The  different  varieties  of  corneal  ulceration  and  suppura- 
tive  inflammation  form  a  very  large  and  important  con- 
tingent of  ophthalmic  cases.  The  fact  that  the  cornea, 
although  a  fibrous  structure,  is  further  removed  from  the 
bloodvessels  than  almost  any  other  tissue,  renders  it  ex- 
tremely susceptible  to  disturbances  of  nutrition  whether 
from  defective  supply  or  bad  quality  of  blood.  Lastly, 
the  surface  of  the  cornea  is  so  delicate,  and  its  perfect  trans- 
parency and  regularity  so  important,  that  slight  injuries 
and  irritations  are  of  more  moment  here  than  in  any  other 
part  of  the  body. 

When  inflamed  the  cornea  always  loses  its  transparency. 
If  only  the  anterior  epithelium  is  involved,  the  surface 
loses  its  polish  and  looks  like  clear  glass  which  has  been 
breathed  upon — "  steamy,"  or  finely  pitted.  This  steami- 
ness  occurs  in  many  states  of  disease. 


DIS EASES     OF    THE    CORNEA.  Ill 

Thickening  of  the  epithelium,  and,  still  more,  exudation 
into  the  corneal  tissue,  are  shown  by  a  white,  grayish,  or 
yellowish  tint. 

If  the  corneal  tissue  be  opalescent,  while  the  surface  is 
at  the  same  time  "  steamy,"  the  term  "  ground-glass  "  gives 
a  good  idea  of  the  appearance,  though  to  make  the  simile 
correct  the  glass  ought  to  be  milky  throughout,  as  well  as 
ground  on  the  surface.  Rapid  suppurative  inflammation 
is  preceded  by  a  stage  of  diffused  opalescence,  and  this  ap- 
pearance is  therefore  a  very  dangerous  sign  in  such  diseases 
as  purulent  ophthalmia,  severe  burns,  or  paralysis  of  the 
fifth  nerve. 

Before  describing  the  most  important  types  of  corueal 
ulcer,  it  is  convenient  to  mention  the  principal  changes  at- 
tendant on  ulceration  of  the  cornea  in  general.  An  ulcer  of 
the  cornea  is  preceded  by  a  stage  of  infiltration,  and  the 
inflamed  spot  is  generally  a  little  raised.  After  the  centre 
of  the  spot  has  broken  down  into  an  ulcer,  some  infiltration 
remains  at  its  base  and  edges,  the  quantity  and  color  of 
which  help  us  to  judge  of  the  probable  course  of  the  case. 
When  the  ulcer  heals  it  leaves  a  hazy  or  opaque  spot 
(leucoma  if  dense,  nebula  if  faint),  which  is  slight  and  will 
often  disappear  entirely  if  superficial,  but  will  in  part  be 
permanent  if  it  result  from  a  deep  ulcer.  These  opacities 
are  likely  to  clear,  cceteris  paribus,  in  proportion  to  the 
youth  of  the  patient ;  time  also  is  a  very  important  element, 
nebulae  often  continuing  to  clear  slowly  for  years.  Local 
stimulation  aids  in  the  removal  of  the  opacities,  one  of  the 
best  applications  being  the  ointment  of  yellow  oxide  of 
mercury  (F.  10).  Some  ulcers  have  scarcely  any  infiltra- 
tion, and  these  for  the  most  part  heal  slowly  with  little  or 
no  opacity ;  but  they  often  cause  permanent  loss  of  sub- 
stance, and  this  is  shown  by  the  presence  of  a  facet  or  flat- 
tened spot  at  the  seat  of  the  former  ulcer.  Such  a  facet, 
even  though  quite  clear,  will,  if  it  lies  over  the  pupil,  in- 


112  DISEASES     OE    THE     CORNEA. 

terfere  \vith  sight  more  than  a  nebula  which  occupies  the 
same  position,  but  does  not  alter  the  regularity  of  the 
corneal  curve.  During  repair  bloodvessels  often  form  and 
pass  from  the  nearest  part  of  the  corueal  edge  to  the  ulcer, 
and  disappear  when  healing  is  complete;  phlyctenular 
ulcers,  however,  are  vascular  from  the  beginning.  Corneal 
opacities  are  of  course  most  serious  when  over  the  pupil. 

The  chief  symptoms  of  corneal  ulceration  are:  (1)  photo- 
phobia, or  at  least  spasm  of  the  orbicularis,  blepharospasm 
(for  it  is  not  always  clear  whether  the  reflex  irritation  starts 
from  the  retina  or  from  the  branches  of  the  fifth  nerve  in 
the  cornea  and  conjunctiva);  (2)  congestion;  (3)  pain. 
All  three  symptoms  vary  extremely  in  degree  in  different 
cases.  As  a  broad  rule,  with  many  exceptions,  we  may  say 
that  intolerance  of  light  is  worse  in  children  than  in  adults, 
worse  with  superficial  than  with  deep  ulcers,  and  worse  in 
persons  who  are  strumous  and  irritable  than  in  those  whose 
tissues  are  healthy  and  tone  good.  Photophobia  should 
always  lead  to  a  careful  inspection  of  the  cornea,  and  Ave 
shall  then  sometimes  be  surprised  to  find  how  slight  a 
change  gives  rise  to  this  symptom  in  its  severest  form. 
The  degree  of  congestion  varies  with  the  seat  and  cause  of 
the  ulcer  and  with  the  patient's  age,  being  usually  greatest 
in  adults.  The  visible  congestion  is,  as  in  iritis,  due  espe- 
cially to  distentiou  of  the  subconjunctival  twigs  of  the 
ciliary  zone  (Fig.  20,  Ant.  Cil.,  and  Fig.  23),  but  there  is 
often  congestion  of  the  conjuuctival  vessels  as  well.  In 
some  forms  of  marginal  ulcer  only  those  vessels  which  feed 
the  diseased  part  are  congested.  Great  pain  in  and  around 
the  eye  often  attends  the  earlier  stages  of  corneal  abscess, 
and  is  common  in  many  acute  ulcers ;  as  a  symptom,  it  of 
course  always  needs  careful  attention ;  it  is  generally  re- 
lieved by  those  local  measures  which  are  best  for  the  dis- 
ease itself. 


DISEASES    OF     THE     CORNEA.  113 


Types  of  Corneal  Ulceration. 

(1)  One  of  the  simplest  forms  is  the  small  central  ulcer 
often  seen  in  young  children.     A  little  grayish-white  spot 
is  seen  at  or  near  the  centre  of  the  cornea,  at  first  elevated 
and  bluntly  conical,  afterwards  showing  a  minute  shallow 
crater;  the  congestion  and  photophobia  varying,  but  often 
slight.     The  ulcer  is  usually  single,  but  is  apt  to  recur  in 
the  same  or  the  other  eye.     The  infiltration  in  many  of 
these  cases  extends  quite  into  the  corneal  tissue,  and  the 
residual  opacity  often  remains  for  a  long  time  if  not  per- 
manently.    The  patients  are  always  badly  nourished  little 
children.     In  most  cases  the  ulcer  quickly  heals,  but  now 
and  then  the  infiltration  passes  into  an  abscess  or  a  spread- 
ing suppurating  ulcer. 

(2)  In  other  cases,  less  common  than  the  above,  one  or 
more  central  ulcers  occur  of  a  much  more  chronic  charac- 
ter, attended  with  little  or  no  infiltration.     After  lasting  for 
months  the  loss  of  tissue  is  only  partly  repaired,  and  a 
shallow   depression    or  a  flat   facet  is   left  with   perhaps 
scarcely  any  loss  of  transparency.     Some  of  the  best  ex- 
amples are  seen  in  anaemic  or  strumous  patients,  with  gran- 
ular lids  of  long  standing. 

(3)  Phlyctenular    ophthalmia  and  phlyctenular  ulcers  of 
cornea  (phlyctenulse,  herpes  cornese,  pustular  ophthalmia, 
marginal  keratitis).     The  formation   of  little  papules  or 
pustules  on  or  near  the  corneal  margin  is  exceedingly  com- 
mon, either  independently  or  as  a  complication  of  some 
existing  ophthalmia.     Although  there  are  many  varieties 
and  degrees  of  phlyctenular  inflammation  in  respect  to  the 
seat,  extent,  and  course  of  the  disease,  the  following  fea- 
tures are  common  to  all.     Phlyctenular  affections  show  a 
strong  tendency  to  recur  during  several  years ;  they  are  sel- 
dom seen  in  very  young  children,  and  comparatively  seldom 

10* 


114  DISEASES     OF     THE     CORNEA. 

after  middle  life;  they  occur  so  often  in  strumous  subjects 
that  we  are  justified  in  strongly  suspecting  scrofulous  ten- 
dencies in  all  who  suffer  much  from  them;  ophthalmia  tarsi 
is  often  seen  in  the  same  patients;  the  first  attack  often 
follows  closely  after  an  acute  exanthem  and  especially  after 
measles;  the  cases  are  much  influenced  by  climate  and 
weather,  and  their  condition  often  varies  extremely  from 
day  to  day  without  making  either  progress  or  regress. 

An  elevated  spot,  like  a  papule,  commonly  about  the 
size  of  a  small  mustard  seed,  is  seen  either  on  the  white  of 
the  eye  near  the  cornea,  or  upon,  or  just  within,  the  cor- 
neal  border.  It  is  preceded  and  accompanied  by  localized 
congestion.  Its  top  sometimes  becomes  as  yellow  as  that 
of  an  acne  pustule,  but  more  often  when  seen  it  has  become 
abraded,  flat,  and  whitish.  Pustules  at  a  little  distance 
from  the  cornea  (Fig.  39),  although  generally  larger  than 

FIG.  39. 


Phlyctenular  ophthalmia,  conjunctival  form.     (Dalrymple.) 

those  seated  on  the  corneal  border,  occasion  less  photopho- 
bia, and  are  more  easily  cured.  Pustules  at  the  corneal 
border,  though  often  very  small,  cause  troublesome  and  even 
very  severe  photophobia;  they  are  troublesome  in  propor- 
tion rather  to  their  number  than  their  size,  and  if  numer- 
ous enough  to  form  a  ring  round  the  cornea,  their  cure  is 
often  most  tedious. 


DISEASES     OF     THE     CORNEA.  115 

A  pustu-le  is  always  liable,  even '  when  it  has  begun  on 
the  conjunctiva,  to  run  as  a  superficial  ulcer  on  to  the  cor- 
nea, though  it  never  extends  in  the  opposite  direction  over 
the  sclerotic.  Such  a  phlyctenular  ulcer,  if  it  do  not  stop 
near  the  corneal  border,  will  make,  in  an  almost  radial  di- 
rection, for  the  centre,  carrying  with  it  a  leash  of  vessels 
which  lie  upon  the  track  of  opacity  left  in  the  wake  of  the 
ulcer  (Fig.  40).  Finally,  the  ulceration  stops,  the  vessels 

FIG.  40. 


Phlyctenular  ulcer.     (Travers.) 

dwindle  and  disappear,  and  the  path  of  opacity  clears  up 
more  or  less.  The  term  recurrent  vascular  ulcer  is  used 
when  such  ulcers  are  solitary ;  but  they  are  often  multiple 
as  well  as  recurrent,  and  the  cornea  may  then  finally  be 
covered  by  a  thin,  irregular  network  of  superficial  vessels 
on  a  patchy,  uneven,  hazy  surface,  the  so-called  "phlycten- 
ular pannus." 

A  variety  of  phlyctenular  inflammation,  aptly  called 
marginal  keratitis  ("spring-catarrh"  of  continental  authors), 
occurs  in  mild  degrees  in  the  form  of  a  slight  granular- 
looking,  often  vascular,  swelling  all  around  the  edge  of  the 
cornea.  If  the  process  continues  the  cornea  is  encroached 
on  by  a  densely  vascular  superficially  ulcerated,  and  yet 
somewhat  thickened  zone.  In  slight  degrees  this  condition 
is  common  enough ;  severe  cases  are  rare  and  very  serious, 
leading  finally  to  implication  of  perhaps  the  greater  part 


116  DISEASES     OF     THE     CORNEA. 

of  the  cornea.  It  often  begins  crescentically  above  and 
below,  as  in  Fig.  46. 

In  another  variety  a  single  pustule  at  the  border  of  the 
cornea  ulcerates  deeply,  becomes  surrounded  by  swollen 
and  infiltrated  tissue,  and  may  perforate ;  such  cases  are 
seen  in  weakly  women  and  strumous  children. 

In  very  rare  cases,  what  appears  to  be  an  ordinary  con- 
junctival  pustule  persists,  grows  deeply,  and  may  even  per- 
forate the  sclerotic  in  the  form  of  an  ulcer;  or  it  may 
infiltrate  the  sclerotic  and  the  ciliary  body  beneath,  form- 
ing a  soft,  semi-suppurating  tumor,  whence  the  inflamma- 
tion is  likely  to  spread  to  the  vitreous  and  destroy  the  eye. 
Stopping  short  of  these  extreme  results,  such  a  case  forms 
one  type  of  episcleritis. 

The  corneal  changes  produced  by  the  friction  of  granu- 
lar lids  have  been  considered  under  that  subject.  The  pan- 
nus  of  granular  lids  can  usually  be  distinguished  from  the 
phlyctenular  pannus  just  mentioned,  by  the  greater  uni- 
formity and  closeness  of  its  vessels,  and  by  its  being  worst 
under  the  upper  lid  (Fig.  38)  ;  any  doubt  is  settled  by 
everting  the  lid.  But  it  must  be  borne  in  mind  that  ulcer- 
ation  of  the  cornea  often  occurs  as  a  complication  of  tra- 
chomatous  pannus  (pp.  107  and  113,  2). 

(4)  A  very  serious  form  of  disease,  commonest  in  the 
senile  period  of  life,  is  the  serpiginous  ulcer.  It  is  often 
comparatively  chronic,  There  is  much  congestion,  and 
often  much  pain  and  photophobia.  With  these  symptoms 
we  find  either  a  marginal  trough-like  or  ditch-like  ulcer, 
with  crescentic  borders,  or  a  more  central  ulcer,  with 
nearly  circular  outline  and  a  varying  amount  of  infiltra- 
tion of  its  walls.  If  the  ulcer  has  lasted  some  little  time 
one  of  its  borders,  the  outer,  if  the  ulcer  be  marginal,  will 
be  partly  healed  and  bevelled  off,  the  floor  of  the  ulcer 
sloping  downwards  to  its  inner  boundary,  which  will  be 
infiltrated,  sharply  cut,  or  even  overhanging. 


DISEASES     OF     THE     COKNEA.  117 

Slight  cases,  taken  early,  generally  give  little  trouble, 
especially  if  the  infiltration  is  insignificant.  But  such  an 
ulcer,  if  neglected,  is  very  likely  to  increase  in  all  dimen- 
sions, to  become  complicated  with  iritis  and  hypopyon,  and 
to  lead  to  perforation  of  the  cornea ;  or  to  spread  slowly 
over  the  whole  cornea,  and  leave  a  dense  scar.  In  either 
event  the  eye  is  much  damaged,  if  not  destroyed. 

(5)  Abscess  of  the  cornea  and  acute  suppurating  ul- 
ceration  are  common  diseases.  Abscess  may  occur  at  any 
age,  but  is  commonest  in  elderly  or  senile  people,  in  whom 
an  abrasion  or  some  slight  injury  by  a  foreign  body  is  not  an 
uncommon  cause,  especially  if  near  the  centre  of  the  cornea. 
The  little  gray  central  ulcers  of  young  children  (p.  113) 
sometimes  go  on  to  abscess.  It  will  very  often  be  noticed 
that  in  cornea!  abscess,  as  well  as  in  the  serpiginous  ulcera- 
tion  just  described,  the  patients  are  either  senile  or  under- 
fed, or  if  vigorous  and  full-blooded  that  they  show  signs 
of  being  damaged  by  drink.  Abscess  of  the  cornea  is 
attended  by  great  pain  and  congestion,  and  the  case  often 
comes  under  care  pretty  early,  though  often  not  till  the 
cornea  has  given  way,  either  in  front  of  or  behind  the  little 
collection.  The  spot  itself  is  generally  small  and  circum- 
scribed ;  it  usually  bursts  forwards,  and  is  converted  into 
an  ulcer,  but  it  may  perforate  the  posterior  surface  of  the 
cornea.  There  is  always  some  haziness  of  the  whole  cornea, 
and  the  purulent  infiltration  may,  if  the  case  do  badly, 
spread  and  involve  almost  its  whole  extent. 

Hypopyon  signifies  a  collection  of  pus  or  puro-lymph  at 
the  lowest  part  of  the  anterior  chamber ;  its  upper  boundary 
is  usually,  but  not  always,  level  (Fig.  41).  It  may  occur 
with  any  acute  ulcer,  whether  deep  or  not,  if  it  be  accom- 
panied by  purulent  infiltration  of  the  surrounding  cornea 
or  with  corneal  abscess ;  or  with  any  corneal  ulcer,  chronic 
or  acute,  in  which  iritis  supervenes.  The  pus  may  be  de- 
rived either  from  an  abscess  breaking  through  the  posterior 


118 


DISEASES     OF     THE     CORNEA. 


surface  of  the  cornea,  or  from  suppuration  of  the  epithe- 
lium covering  Descemet's  membrane,  or  from  the  surface 
of  the  iris.  Simple  iritis  now  and  then  gives  rise  to  hypo- 
pyon  (see  Rheumatic  Iritis). 


FIG.  41. 


Hypopyon,  seen  from  the  front,  and  in  section,  to  show  that  the  pus 
is  behind  the  cornea. 

In  many  cases  of  severe  corneal  suppuration  (a,  Fig.  42) 
the  pus  sinks  clown  between  the  lamellte  of  the  cornea  (6). 
To  this  condition  the  term  onyx  is  applied,  and  should  be 

FIG.  42. 


a.  Abscess.     6.  Onyx. 

limited,  though  it  is  sometimes  used  in  other  senses.  The 
term,  however,  may  very  well  be  discarded.  Onyx  and 
hypopyon  often  coexist,  and  then  the  distinction  between 


DISEASES     OF     THE     CORNEA.  119 

them  can  hardly  be  made  without  tapping  the  anterior 
chamber.  Hypopyon,  however,  when  liquid,  will  change 
its  position  if  the  patient  lies  down,  but  as  it  is  more  often 
gelatinous  or  fibrinous,  this  test  loses  much  of  its  value ; 
oblique  illumination  will  sometimes  show  the  cornea  clear 
in  front  of  an  hypopyon;  and  as  the  diameter  of  the  an- 
terior chamber  is  a  little  greater  than  the  apparent  diame- 
ter of  the  clear  cornea,  a  very  small  hypopyon  is  almost 
hidden  behind  the  overlapping  edge  of  the  sclerotic,  and 
may  escape  detection. 

Treatment  of  Ulcers  of  the  Cornea. 

The  general  principles  of  local  treatment  suitable  to  the 
different  types  of  ulceration  are :  (1)  By  bandaging  the 
affected  eye  or  by  shading  both  eyes,  to  prevent  movement 
of  the  lids,  and  thus  secure  rest  for  the  ulcerated  surface. 
(2)  To  soothe  local  pain,  and  diminish  congestion,  by  atro- 
pine.  (3)  To  relieve  the  tension  of  the  ulcerated  surface, 
and  so  favor  healing.  Atropine  has  been  believed  to  owe 
part  at  least  of  its  good  effect  in  cases  of  corneal  ulcer  to 
a  power  of  lessening  the  tension  of  the  eye,  but  this  is  un- 
likely, since  it  certainly  increases  tension  in  eyes  threat- 
ened, or  affected,  with  glaucoma.  Eserine  probably  owes 
much  of  its  beneficial  effect  in  ulcer  cases  to  its  undoubted 
power  of  lowering  tension.  But  in  severe  cases  some  opera- 
tive measure,  which  at  the  same  time  will  let  out  any  pus 
that  may  be  present  in  the  anterior  chamber  is  best.  (4) 
In  suppurating  cases,  to  induce  granulation  instead  of 
suppuration,  and  absorption  of  the  pus  already  effused. 
Frequent  hot  fomentations  to  the  eyelids  attain  this  end 
better  than  any  other  means  in  a  large  number  of  cases. 
(5)  Stimulation  of  the  surface  of  the  ulcer  when  it  has 
begun  to  heal,  especially  if  it  be  indolent.  The  best  stimu- 
lants are  calomel,  yellow  oxide  of  mercury,  and  nitrate  of 
silver.  (6)  Counter-irritation  by  a  seton  in  the  temple  is 


120  DISEASES     OF     THE     CORNEA. 

of  very  great  use  in  chronic  irritable  ulcers.  (7)  When 
ulcers  are  caused  by  granular  lids,  the  treatment  of  the 
granular  disease  is  more  important  than  that  of  the  ulcera- 
tion,  unless  the  latter  be  of  threatening  character. 

The  choice  of  one  or  another  of  the  above  plans  is  easy 
enough  in  a  large  proportion  of  cases ;  in  others  a  good 
deal  of  judgment  is  needed  ;  while  in  a  certain  number  it 
is  impossible  to  say  with  any  certainty  what  will  be  found 
most  beneficial. 

Ulcers  of  the  cornea  are  so  often  a  sign  of  bad  health 
that  the  improvement  of  the  general  state  should  always 
receive  most  careful  attention. 

Treating  the  matter  clinically  we  shall  find  that  local 
stimulation  is  best  for  a  large  majority  of  the  cases  as  they 
first  come  under  notice,  including  phlyctenular  cases, 
chronic  superficial  ulcers  of  various  kinds,  and  even  many 
recent  ulcers  if  not  threatening  to  suppurate.  As  a  general 
rule,  this  plan  is  not  suitable  when  there  is  much  photo- 
phobia, but  exceptions  to  the  rule  are  found,  especially  in 
old-standing  cases.  The  most  convenient  remedy  is  the 
ointment  of  amorphous  yellow  oxide  of  mercury  (F.  10 
and  11),  of  which  a  piece  about  as  large  as  a  hemp-seed  is 
to  be  put  inside  the  eyelids  once  or  twice  a  day.  If  smart- 
ing continue  for  more  than  half  an  hour,  the  ointment  should 
be  washed  out  with  warm  water;  and  if  the  eye  become 
more  irritable  after  a  few  days'  use  of  the  ointment  it  must 
be  weakened  or  discontinued.  The  same  ointment  com- 
bined with  atropine  gives  excellent  results  in  cases  of  super- 
ficial ulcer  with  much  photophobia.  Calomel  flicked  into 
the  eye  daily  or  less  often  is  an  admirable  remedy  in  many 
cases.  Kitrate  of  silver  in  the  form  of  solid  mitigated  stick 
is  useful  if  carefully  applied  to  large  conjunctival  pustules, 
and  occasionally  to  indolent  corneal  ulcers ;  its  use,  how- 
ever, needs  some  skill,  and  is  seldom  really  necessary.  Solu- 
tions of  from  5  to  10  grains  to  the  ounce  may  be  cautiously 


DISEASES     OF     T1IE     CORNEA.  121 

used  by  the  surgeon  instead  of  the  yellow  ointment,  and 
are  particularly  valuable  in  old  vascular  ulcers  and  when 
there  is  conjunctivitis.  When  in  doubt,  it  is  best  to  depend 
for  a  few  days  on  atropinc  alone,  used  just  often  enough  to 
cause  wide  dilatation  of  the  pupil. 

Severe  and  obstinate  photophobia,  especially  in  young 
children,  is  best  treated  by  a  free  division  of  all  the  tissues 
at  the  outer  canthus,  which  renders  spasm  impossible  for  a 
time,  and  allows  the  remedies  to  be  efficiently  used.  In  all 
cases  of  corneal  disease  attended  with  intolerance  of  light 
the  patient  is  to  wear  a  large  shade,  or,  better,  a  pair  of 
"  S°SS^es  "  °ver  both  eyes ;  a  little  patch  over  one  eye  does 
not  relieve  photophobia.  Many  a  child  is  kept  within 
doors  to  the  injury  of  its  health  who,  with  suitable  protec- 
tion, can  go  out  daily  without  the  least  detriment  to  its 
eyes. 

In  chronic  and  relapsing  cases,  with  photophobia  and 
irritability,  where  other  methods  have  had  a  fair  trial,  a 
seton  gives  the  best  results,  whether  or  not  there  be  much 
congestion  of  the  eye.  A  double  thread  of  thick  silk  is 
used,  and  at  least  an  inch  of  skin  included  between  the 
punctures,  which  are  placed  amongst  the  hair  of  the  temple 
or  behind  the  ear,  that  the  resulting  scar  may  be  hidden  ; 
it  is  to  be  moved  daily,  and  if  acting  badly  may  be  dressed 
with  savin  ointment.  The  seton  should  be  worn  at  least 
six  weeks.  Severe  inflammation,  and  even  abscess,  some- 
times sets  in  a  few  days  after  the  insertion  of  the  thread, 
and  in  very  rare  cases  severe  secondary  bleeding  has  oc- 
curred from  a  branch  of  the  temporal  artery.  To  avoid 
wounding  the  artery  in  inserting  the  seton  in  the  temple, 
the  skin  is  to  be  held  well  away  from  the  head. 

Very  severe  recent  phlyctenular  cases  are  occasionally 
difficult  to  influence,  and  remain  practically  "blind  "  with 
spasm  of  the  lids  for  weeks.  There  is  seldom  any  risk, 
provided  that  we  thoroughly  examine  the  cornea  at  inter- 

11 


122  DISEASES     OF     TI1E     CORNEA. 

vals  of  a  few  days,  and  they  generally  in  the  end  recover 
well.  Calomel  dusted  on  the  cornea  sometimes  helps  more 
than  any  other  local  measure,  and  change  of  air,  especially 
to  the  seaside,  frequently  effects  a  more  rapid  cure  than  any 
plan. 

Cases  for  which  the  stimulating  treatment  is  suitable 
seldom  need  the  eye  to  be  bandaged,  though,  as  mentioned, 
they  often  need  a  shade  or  goggles. 

The  remaining  methods  of  treatment — protective  ban- 
daging, atropine,  eserine,  hot  fomentations,  and  operative 
measures — are  reserved  for  the  more  serious  forms  of  ulcer- 
ation,  the  serpiginous  ulcer,  acute  suppurating  ulcers,  ab- 
scesses, and  generally  for  all  ulcers  with  hypopyon,  and 
ulcers  which  are  deep  and  threaten  to  perforate.  The 
compress  used  for  this  purpose  consists  of  a  pad  of  cotton- 
wool and  a  single  turn  of  bandage,  tied  at  the  back  of  the 
head ;  a  piece  of  linen  rag  should  t>e  placed  next  the  skin 
to  prevent  irritation  by  the  wool ;  such  a  compress  is  most 
grateful  in  the  irritation  caused  by  a  corneal  abrasion,  or 
after  a  foreign  body  has  been  removed  (p.  164).  Atropine 
is  to  be  used  regularly  from  three  to  six  times  a  day,  on 
the  ground  that  iritis,  if  not  present,  is  very  likely  to  occur ; 
it  also  soothes  pain  and  diminishes  congestion.  Hot  fomen- 
tations are  extremely  valuable.  I  generally  direct  that 
the  compress  be  removed  every  two  hours,  or  sometimes 
every  hour,  and  the  lids  fomented  for  fifteen  or  twenty 
minutes  with  a  belladonna  lotion  (one  drachm  of  extract 
to  the  pint)  made  as  hot  as  can  be  borne.  If  atropine  be 
properly  used,  there  is  no  actual  need  for  the  belladonna ; 
hot  water  or  poppy-head  fomentation  is  as  good.  Many 
cases  of  acute  suppurating  ulcer,  of  serpiginous  ulcer,  and 
of  abscess,  quickly  recover  under  this  treatment,  combined 
with  the  administration  of  bark  or  quinine  with  ammonia 
and  ether.  Even  a  considerable  hypopyon  will  often  be 
quickly  absorbed. 


DISEASES     OF     THE     CORNEA.  123 

But  the  ulceration  may  increase,  or  the  hypopyon,  if 
present,  enlarge.  If  so,  the  hypopyon  is  to  be  evacuated 
by  an  incision  close  to  the  margin  of  the  cornea.  Some 
surgeons  prefer  at  the  same  time  to  make  an  iridectomy, 
but  the  effect  of  removal  of  iris  upon  the  progress  of  the 
inflammation  is  doubtful.  I  incline  to  think  that  a  pam- 
centesis  with  a  broad  needle,  repeated  if  the  hypopyon  re- 
form in  a  few  days,  is  all  that  is  needed.  Another  method 
is  to  evacuate  the  aqueous  by  cutting  across  the  whole 
width  of  the  ulcer,  and  by  opening  the  wound  daily  with 
a  probe,  to  keep  the  cornea  flaccid  until  healing  is  well  es- 
tablished ;  this  method  was  intended  by  its  author  (Sae- 
misch)  especially  for  the  serpiginous  ulcers.  In  corneal 
abscess  a  similar  incision  is  often  made  across  the  inflamed 
spot  into  the  anterior  chamber.  In  these  operations  the 
hypopyon  will  usually  escape  through  the  incision,  and 
after  all  of  them  the  anterior  chamber  will  leak  for  a  longer 
or  shorter  time,  according  to  the  size  of  the  incision.  Prob- 
ably iridectomy  is  often  so  beneficial  because  the  incision 
is  too  large  to  close  at  once,  and  I  have  several  times  seen 
the  best  results  from  a  wound  made  as  for  iridectomy,  but 
without  the  removal  of  any  iris.  When  an  acute  ulcer 
without  hypopyon  is  just  about  to  perforate,  puncture  of 
its  transparent  protruding  floor,  with  a  needle,  will  aid  the 
healing. 

It  is  well  known  that  atropine  does  not  suit  all  cases  of 
suppurative  inflammation  and  ulceration  of  the  cornea, 
particularly  if  there  be  decided  conjunctivitis  with  dis- 
charge. Eserine  (F.  29)  has  come  largely  into  use  within 
the  last  few  years  for  many  cases  of  suppurative  ulcer 
accompanied  by  much  infiltration,  for  which  atropine  was 
formerly  employed.  I  have  used  it  largely,  but  hitherto 
without  being  able  to  draw  decided  conclusions,  either  as 
to  the  cases  in  which  it  will  be  well  borne,  or  as  to  its 
effect  in  favoring  absorption.  The  almost  universal  custom 


124  DISEASES     OF     THE     CORNEA. 

of  using  hot  applications  to  the  lids  renders  it  difficult  to 
draw  trustworthy  conclusions  as  to  the  effect  of  eserine. 
Antiseptic  dressings  are  also  being  largely  used ;  a  4  per 
cent,  solution  of  boracic  acid  is  the  most  suitable  solution 
for  the  eye,  whether  for  bathing  or  continuous  application 
by  a  pad. 

I  have  occasionally  seen  a  good  result  from  the  use  of 
cold  evaporating  lotions  in  irritable  superficial  ulcers,  with 
much  spasm  of  lids,  which  have  resisted  other  treatment. 

Conical  cornea. — In  this  condition  the  central  part  of 
the  cornea  very  slowly  bulges  forwards,  forming  a  bluntly 
conical  curve.  The  focal  length  of  the  affected  part  of  the 
cornea  is  thereby  shortened,  and  the  eye  becomes  myopic, 
not  owing  to  increase  of  its  length  but  from  increase  of  re- 
fractive power.  The  curvature,  however,  is  not  uniform, 
and  hence  irregular  astigmatism  complicates  the  myopia. 

The  disease,  which  is  rare,  occurs  chiefly  in  young  adults, 
especially  women,  and  is  often  dated  from  some  illness  or 
failure  of  general  health ;  and  it  appears  to  be  due  to  de- 
fective nutrition  of  that  part  of  the  cornea  which  is  furth- 
est from  the  bloodvessels.  In  advanced  cases  the  protru. 
sion  of  the  cornea  is  very  evident,  whether  viewed  from  the 
front  or  from  the  side,  but  slight  degrees  are  less  easily  dis- 
tinguished from  ordinary  myopic  astigmatism  (see  Irregu- 
lar Astigmatism).  In  high  degrees  the  apex  of  the  cone 
often  becomes  nebulous.  The  disease  may  progress  to  a 
high  degree,  or  stop  before  great  damage  has  been  done. 
Concave  glasses  alone  are  of  little  use,  but  in  combination 
with  a  screen  perforated  by  a  narrow  slit  or  small  central 
hole,  which  allows  the  light  to  pass  only  through  the  cen- 
tre, or  through  some  one  meridian,  of  the  cornea,  they  are 
sometimes  useful.  In  advanced  cases  operation  is  needed. 
(See  Operations.) 


DISEASES    OF     THE     CORNEA.  125 


B.  DIFFUSE  KERATITIS. 

Syphilitic,  Interstitial,  Parenchymatous,  or  " Strumous" 
Keratitis. 

In  this  disease  the  cornea  in  its  whole  thickness  under- 
goes a  chronic  inflammation,  which  shows  no  tendency 
either  to  the  formation  of  pus  or  to  ulceration.  After  sev 
eral  months  the  inflammatory  products  are  either  wholly 
or  in  great  part  absorbed,  and  the  transparency  of  the  cor- 
nea restored  in  proportion. 

The  changes  in  the  cornea  are  usually  preceded  for  a 
few  days  by  some  ciliary  congestion  and  watering.  Then 
a  faint  cloudiness  is  seen  in  one  or  more  large  patches,  and 
the  surface,  if  carefully  looked  at,  is  found  to  be  "steamy" 
(p.  110).  These,  nebulous  areas  may  lie  in  any  part  of  the 
cornea.  In  from  two  to  about  four  weeks  the  whole  cornea 
has  usually  passed  into  a  condition  of  white  haziness  with 
steamy  surface,  of  which  the  term  "  ground  glass "  gives 

FIG.  43. 


Interstitial  keratitis. 

the  best  idea.  Even  now,  however,  careful  inspection, 
especially  by  focal  light,  will  show  that  the  opacity  is  by 
no  means  uniform,  that  it  shows  many  whiter  spots  or  large 
denser  " clouds "  scattered  among  the  general  "mist;"  in 
very  severe  cases  the  whole  cornea  is  quite  opaque  and  the 
iris  hidden ;  but,  as  a  rule,  the  iris  and  pupil  can  be  seen, 
though  very  imperfectly  (Fig.  43).  In  many  cases  iritis 
takes  place,  and  posterior  synechiae  are  formed.  Blood- 
vessels derived  from  branches  of  the  ciliary  vessels  (Fig. 

11* 


126 


DISEASES    OF     THE     CORNEA. 


20)  are  often  formed  in  the  layers  of  the  cornea  (Fig.  44) ; 
they  are  small  but  thickly  set,  and  in  patches ;  as  they  are 
covered  by  a  certain  thickness  of  hazy  cornea,  their  bright 
scarlet  is  toned  down  to  a  dull  reddish-pink  color  ("  salmon 


FIG.  44. 


Thickening  of  cornea  and  formation  of  vessels  in  its  layers  in  syphilitic 
keratitis.     Subconjunctival  tissue  thickened.     X  about  10  diameters. 

patch"  of  Hutchinson).  The  separate  vessels  are  visible 
only  if  magnified  (p.  61),  when  we  see  that  the  trunks 
passing  in  from  the  border  divide  at  acute  angles  into  very 
numerous  twigs,  lying  close  to  each  other  and  taking  a 

FIG.  45. 


Vessels  in  interstitial  keratitis. 


nearly  straight  course  towards  the  centre  (Fig.  45).  These 
salmon-patches  are  of  no  constant  form,  but  when  small 
are  often  crescentic,  and  tend  when  large  to  the  sector- 


DISEASES     OF     THE     CORNEA.  127 

shape.  In  another  type  the  vascularity  begins  as  a  nar- 
row fringe  of  looped  vessels  which  are  continuous  with  the 
superficial  loop-plexus  of  the  corneal  margin  (Fig.  46,  com- 
pare Fig.  20,  0>  au(i  gradually  extend  from  above  and  be- 
low towards  the  centre.  The  vessels  in  these  cases  are 
more  superficial,  and  the  corneal  tissue  in  which  they  lie  is 
always  swollen  by  infiltration.  These  cases  are  described 
as  "marginal  keratitis"  by  some  authors  (compare  p.  115); 
nearly  all  the  examples  occur  in  syphilitic  subjects,  but  I 
believe  that  some  of  the  patients  are  at  the  same  time  stru- 
mous.  A  similar  disease,  ending  in  loss  of  the  eye,  some- 
times from  glaucoma,  occurs  now  and  then  in  elderly  people. 
In  extreme  cases  of  either  type  of  vascular  keratitis  the 
vessels  occupy  the  whole  cornea  except  a  small  central 
island. 

FIB.  46. 


Marginal  vascular  keratitis. 

The  degree  of  congestion  and  the  subjective  symptoms 
in  syphilitic  keratitis  vary  very  much ;  as  a  general  rule 
there  is  but  moderate  photophobia  and  pain,  but  when  the 
ciliary  congestion  is  great  these  symptoms  are  sometimes 
very  severe  and  protracted. 

The  attack  can  be  shortened  and  its  severity  lessened  by 
treatment ;  but  the  disease  is  always  slow,  and  from  six  to 
twelve  months  may  be  taken  as  a  fair  average  for  its  dura- 
tion from  beginning  to  end.  Very  bad  cases  Avith  exces- 


128  DISEASES     OF     THE     CORNEA. 

sively  dense  opacity  sometimes  continue  to  improve  for 
several  years,  and  reach  a  very  unexpected  degree  of  sight. 
Perfect  recovery  of  transparency  is  less  common,  even  in 
moderate  cases,  than  is  sometimes  supposed,  but  the  slight 
degree  of  haziness  which  so  often  remains  does  not  much 
affect  the  sight.  The  epithelium  usually  becomes  smooth 
before  the  cornea  becomes  transparent ;  but  in  severe  cases 
irregularities  of  surface  and  straggling  superficial  vessels 
may  remain  and  render  the  diagnosis  difficult. 

Syphilitic  keratitis  is  almost  always  symmetrical,  though 
an  interval  of  a  few  weeks  commonly  separates  its  onset  in 
the  two  eyes ;  rarely  the  interval  is  several  months,  or  even 
longer.  It  generally  occurs  between  the  ages  of  6  and  15; 
sometimes  as  early  as  2  z  or  3  years,  and  very  rarely  as  late 
as  35.  When  it  occurs  at  a  very  early  age  the  attack  is 
generally  mild.  Relapses  of  greater  or  less  severity  are 
common.  Not  only  does  iritis  occur  with  tolerable  fre- 
quency, but  we  occasionally  meet  with  deep-seated  inflam- 
mation in  the  ciliary  region,  giving  rise  either  to  secondary 
glaucoma,  or  to  stretching  and  elongation  of  the  globe  in 
the  ciliary  zone,  or  to  softening  and  shrinking  of  the  eye- 
ball.1 Dots  of  opacity  may  sometimes  be  seen  on  the  lower 
part  of  the  back  of  the  cornea  before  the  cornea  itself  is 
much  altered  (p.  130) ;  sometimes,  too,  the  interstitial  ex- 
udation is  much  more  dense  at  thejower  part  of  the  cor- 
nea than  elsewhere.  Syphilitic  keratitis  in-  strumous 
children  often  presents  more  irritability  and  photophobia, 
and  more  conjunctival  congestion,  than  in  others;  but  it  is 
very  seldom  that  ulceration  occurs ;  and  although  in  the 
worst  cases  the  cornea  becomes  softened  and  yellowish,  and 
for  a  time  seems  likely  to  give  way,  actual  perforation  and 
% 

1  Patches  of  atrophy  after  choroiditis  are  often  found  after  the 
cornete  have  cleared.  Probably  in  most  of  these  the  active  choro- 
iditis took  place  long  before  the  keratitis  set  in. 


DISEASES    OF     THE     CORNEA.  129 

staphylomatous  bulging  are  amongst  the  rarest  events. 
Pannus  from  granular  disease  may  coexist  with  syphilitic 
keratitis. 

TREATMENT. — A  long  but  rnild  course  of  mercury  exerts 
an  undoubtedly  good  eifect.  It  is  customary  to  give  iodide 
of  potassium  also,  and  it  probably  has  some  influence.  If, 
as  is  often  the  case,  the  patients  are  very  ausemic,  iron, 
or  the  syrup  of  the  iodide  of  iron,  is  sometimes  more 
useful  than  iodide  of  potassium  as  an  adjunct  to  the 
mercury.  Locally,  the  use  of  atropine  is  advisable  as  a 
routine  practice  until  the  disease  has  reached  its  height,  on 
the  ground  that  iritis  may  be  present.  In  cases  attended 
by  severe  and  prolonged  photophobia  and  ciliary  conges- 
tion, setons  in  the  temples  sometimes  give  relief.  In  similar 
cases  iridectomy  is  sometimes  followed  by  rapid  improve- 
ment ;  but  the  cases  in  which  this  operation  is  needed  or 
justifiable  are  not  numerous.  When  all  inflammatory 
symptoms  have  subsided,  the  local  use  of  yellow  ointment 
or  calomel  (F.  9  and  10)  appears  to  aid  the  absorption  of 
the  residual  opacity. 

The  form  of  keratitis  above  described  is  caused  by  in- 
herited syphilis.  In  a  few  very  rare  cases  it  has  been  seen 
as  the  result  of  secondary  acquired  syphilis.  Other  cases 
of  diffuse  keratitis  occur  in  which  syphilis  has  no  share, 
but  they  are  seldom  symmetrical,  nor  do  they  occur  early 
in  life.  That  diffuse  chronic  keratitis  affecting  both  eyes 
of  children  and  adolescents  is,  when  well  characterized, 
almost  invariably  the  result  of  hereditary  syphilis  is  proved 
by  abundant  evidence.  A  large  proportion  of  its  subjects 
show  some  of  the  other  signs  of  hereditary  syphilis  in  the 
teeth,  skin,  ears  (deafness\  physiognomy,  mouth,  or  bones. 
When  the  patients  themselves  show  no  such  signs,  a  history 
of  infantile  syphilis  in  the  patient  or  in  some  brothers  or 
sisters,  or  of  acquired  syphilis  in  one  or  other  parent,  may 


130  DISEASES    OF     THE     CORNEA. 

often  be  obtained.1  That  this  keratitis  stands  in  no  causal 
relation  to  struma  is  clear,  because  the  ordinary  signs  of 
struma  are  not  found  oftener  in  its  victims  than  in  other 
children,  because  persons  who  are  decidedly  strumous  do 
not  suffer  from  this  keratitis  more  often  than  others,  and 
because  the  forms  of  eye  disease  which  are  universally 
recognized  as  "strumous"  (ophthalmia  tarsi,  phlyctenular 
disease,  and  relapsing  ulcers  of  cornea)  very  seldom  accom- 
pany this  diffuse  keratitis. 

Other  forms  of  Keratitis. 

Inflammation  of  the  cornea  forms  a  more  or  less  con- 
spicuous feature  in  several  diseases  where  the  primary  or 
principal  seat  of  mischief  is  in  some  other  part  of  the  eye. 
It  is  important  for  purposes  of  diagnosis  to  compare  these 
secondary  or  complicating  forms  of  keratitis  with  the  primary 
diseases  of  the  cornea  already  described. 

In  cases  of  iritis  the  lower  half  of  the  cornea  often  be- 
comes steamy,  and  its  tissue  more  or  less  hazy.  In  some 
cases  a  number  of  small  separate  opaque  dots  are  seen  on 
the  posterior  elastic  lamina  (Descemet's  membrane),  often 
so  minute  as  to  need  a  hand-lens  for  their  detection  (p.  61). 
In  other  cases  a  few  large  dots  only  are  present,  or  a  mix- 
ture of  large  and  small.  They  are  sharply  defined,  the 
large  ones  looking  very  like  minute  drops  of  cold  gravy- 
fat,  the  smallest  like  grains  of  gray  sand;  in  cases  of  long 
standing  they  may  be  either  very  white  or  highly  pig- 
mented.  They  are  generally  arranged  in  a  triangle,  with 
its  apex  towards  the  centre  and  its  base  at  the  lower  mar- 
gin of  the  cornea,  and  the  smallest  dots  are  commonly 
nearest  the  centre  (Fig.  47),  but  in  some  cases  (sympathetic 

1  I  have  found  other  personal  evidence  of  inherited  syphilis  in 
54  per  cent,  of  my  cases  of  interstitial  keratitis,  and  evidence  from 
the  family  history  in  14  per  cent,  more ;  total,  68  per  cent. ;  and 
in  most  of  the  remaining  32  per  cent,  there  have  been  strong  rea- 
sons to  suspect  syphilis. 


DISEASES    OF     THE     CORNEA.  131 

ophthalmitis  especially)  the  dots  are  scattered  over  the 
\vhoie  area.  They  are,  of  course,  difficult  to  detect  in  pro- 
portion as  the  corneal  tissue  itself  has  lost  its  transparency. 
The  terra  keratitis  punctata,  is  used  to  express  this  accu- 
mulation of  dots  on  the  back  of  the  cornea,  and  by  some 
authors  is  made  to  include  also  small  spots  with  hazy  out- 

FIG.  47. 


Keratitis  punctata. 

lines,  which  lie  in  the  cornea  proper,  and  are  sometimes 
seen  in  similar  cases.  Keratitis  punctata  is,  almost  with- 
out exception,  secondary  to  some  disease  of  the  cornea,  iris, 
or  choroid  and  vitreous.  But  a  few  cases  are  seen,  chiefly 
in  young  adults,  where  the  cornealdots  form  the  principal 
if  not  the  sole  visible  change ;  the  number  of  these  cases 
diminishes,  however,  in  proportion  to  the  care  Avith  which 
other  lesions  are  sought  (p.  149). 

It  is  now  and  then  difficult  to  say  whether  the  iritis  or 
keratitis  in  a  mixed  case  has  been  the  initial  change ;  but 
when  this  doubt  arises  the  cornea  has  generally  been  the 
starting-point;  and  with  care  we  are  seldom  at  a  loss  to 
decide  whether  the  case  is  one  of  syphilitic  keratitis  with 
iritis,  or  of  sclerotitis  with  corneal  mischief  and  iritis,  or  of 
primary  iritis  with  an  unusual  degree  of  corneal  haze. 
(See  Ciliary  Region  and  Iritis.) 

Slight  loss  of  transparency  of  the  cornea  occurs  in  most 
cases  of  glaucoma.  The  earliest  change  is  a  fine  uniform 
steaminess  of  the  epithelium.  In  very  severe  acute  cases 
the  cornea  becomes  hazy  throughout,  though  not  in  a  high 
degree.  The  same  haze  occurs  in  chronic  cases  of  long 
standing,  with  great  increase  of  tension,  but  the  epithelial 
"steaminess"  often  then  gives  place  to  a  coarser  "pitting," 


132  DISEASES     OF     THE     CORNEA. 

with  little  depressions  and  elevations  (vesicles),  especially 
on  the  part  which  is  uncovered  by  the  lids. 

A  peculiar  and  rare  form  of  corneal  disease,  seen  in 
elderly  or  prematurely  senile  persons,  is  the  transverse 
calcareous  film,  an  elongated  patch  of  light  gray  opacity, 
looking  when  magnified  like  very  fine  sand,  placed  beneath 
the  epithelium  and  running  almost  horizontally  across  the 
cornea.  It  consists  of  minute  crystals,  chiefly  calcareous. 

Arcus  senilis  is  caused  by  fatty  degeneration  of  the  cor- 
neal tissue  just  within  its  margin  (Fig.  48).  It  generally 

FIG.  48. 


Arcus  senilis.     (Canton.) 

begins  beneath  the  upper  lid,  and  next  appears  beneath  the 
lower,  forming  two  narrow,  white  or  yellowish  crescents, 
the  horns  of  which  finally  meet  at  the  sides  of  the  cornea ; 
it  always  begins,  and  remains  most  intense,  on  a  line  slightly 
within  the  sclero-corneal  junction,  and  the  degeneration  is 
most  marked  in  the  superficial  layers  of  the  cornea  beneath 
the  anterior  elastic  lamina;  in  other  words,  the  change  is 
greatest  at  the  part  most  influenced  by  the  marginal  blood- 
vessels. It  is  not  found  to  interfere  with  the  union  of  a 
wound  carried  through  it,  though  the  tissue  of  the  arcus  is 
often  very  tough  and  hard.  Nevertheless,  its  occurrence 
chiefly  at  an  advanced  age,  and  its  frequent  coexistence 
with  fatty  degeneration,  both  in  distant  parts  and  in  the 
bloodvessels  and  muscles  of  the  eyeball,  mark  it  as  a  truly 
senile  change. 


DISEASES     OF     THE     CORNEA.  133 

Less  regular  forms  of  amis  are  seen  as  the  result  of  pro- 
longed or  relapsing  inflammations  near  the  corneal  border, 
whether  ulcerative  or  not.  It  is  generally  easy  to  dis- 
tinguish such  an  arcus,  because  the  opacity  is  denser,  more 
patchy,  and  its  outlines  less  regular  than  in  the  primary 
form  ;  when  arcus  is  seen  unusually  early  in  life  it  is  gen- 
erally of  this  inflammatory  kind,  for  simple  arcus  is  com- 
paratively rare  below  forty. 

Opacity  of  a  very  characteristic  kiud  is  likely  to  follow 
the  use  of  a  lotion  containing  lead  when  the  surface  of  the 
cornea  is  abraded.  An  insoluble,  densely  opaque  and  very 
white  film  of  lead  salts  is  precipitated  on  the  ulcerated 
surface,  and  adheres  very  firmly  to  it.  Such  an  opacity 
when  once  seen  can  scarcely  be  mistaken ;  it  is  sharply  de- 
fined, and  looks  like  white  paint.  If  precipitated  on  a 
deep  and  much  inflamed  ulcer,  the  film  of  tissue  to  which 
it  adheres  is  often  thrown  off;  but  when  there  is  only  a 
superficial  abrasion  or  ulcer,  the  lead  adheres  very  firmly, 
and  can  only  be  scraped  off  imperfectly.  But  even  in 
these  cases  the  layer  is  probably  after  a  time  thrown  off  or 
worn  off,  if  we  may  judge  by  the  fact  that  nearly  all  the 
lead  opacities  which  come  under  notice  are  comparatively 
new.  The  practical  lesson  is,  never  to  use  a  lead  lotion  for 
the  eye  when  there  is  any  suspicion  that  the  corneal  surface 
is  broken.  Powdered  acetate  of  lead  rubbed  into  the  con- 
junctiva (a  treatment  sometimes  used  for  granular  lids),  is, 
I  believe,  not  attended  by  risk  of  corneal  opacity,  even 
though  there  be  ulceration ;  the  lead  is  precipitated  at 
once,  and  adheres  for  weeks  to  the  surface  of  the  granular 
conjunctiva,  any  superfluous  salt  being  washed  away  with 
water  immediately  after  the  powder  has  been  applied. 

The  prolonged  use  of  nitrate  of  silver,  whether  in  a  weak 
or  strong  form,  is  sometimes  followed  by  a  dull  (brownish- 
green),  permanent  discoloration  of  the  conjunctiva,  and 
even  the  cornea  may  become  slightly  stained. 

12 


134  DISEASES     OF     THE     IRIS. 


CHAPTER  IX. 

DISEASES   OF    THE    IRIS. 

IRITIS. 

INFLAMMATION  of  the  iris  may  be  caused  by  certain 
specific  blood  diseases,  especially  syphilis ;  or  may  be  the 
expression  of  a  tendency  to  relapses  of  inflammation  in 
certain  tissues  under  the  influence  largely  of  climate  and 
weather — rheumatic  iritis ;  it  often  occurs  in  the  course  of 
ulcers,  and  of  wounds  and  other  injuries,  of  the  cornea; 
also  with  diffuse  keratitis  and  sclerotitis ;  iritis  forms  a  very 
important  part  of  the  grave  and  peculiar  disease  known  as 
sympathetic  ophthalmitis. 

Acute  iritis,  from  whatever  cause,  is  shown  by  a  change 
in  the  color  of  the  iris,  by  indistinctness  or  "  muddiness  " 
of  its  texture,  by  diminution  of  its  mobility,  and  by  the 
existence  of  adhesions  (posterior  synechice)  between  its  pos- 
terior (uveal)  surface  and  the  capsule  of  the  lens ;  there  is, 
besides,  in  most  cases,  a  duluess  of  the  whole  iris  and  pupil, 
caused  partly  by  slight  corneal  changes  (p.  130),  partly  by 
muddiness  of  the  aqueous  humor.  The  eyeball  is  con- 
gested and  sight  is  almost  always  defective.  There  may  or 
may  not  be  pain,  photophobia,  and  lachrymation. 

The  congestion  is  often  nearly  confined  to  a  zone  of 
about  one-twelfth  or  one-eighth  of  an  inch  wide,  which  sur- 
rounds the  cornea,  its  color  being  pink  (not  raw  red),  the 
vessels  small,  radiating,  and  nearly  straight,  and  lying  be- 
neath the  conjunctiva  (ciliary  or  circum-corneal  congestion}. 
These  are  the  episcleral  branches  of  the  anterior  ciliary 


DISEASES     OF     THE     IRIS.  135 

arteries  (p.  38).  Quite  the  same  congestion  is  seen  in  many 
other  conditions,  e.  g.,  corneal  ulceration  (p.  112) ;  whilst  on 
the  other  hand,  in  some  cases  of  iritis,  the  superficial  (con- 
junctival)  vessels  are  congested  also,  especially  in  their 
anterior  divisions,  which  are  chiefly  offshoots  of  the  ciliary 
system  (Fig.  20).  We  therefore  never  diagnose  iritis  from 
the  character  of  the  congestion  alone;  but  iritis  being 
proved  by  the  other  symptoms,  the  kind  and  degree  of  con- 
gestion help  us  to  judge  of  its  severity. 

The  altered  color  of  the  iris  is  explained  by  its  conges- 
tion, and  by  the  effusion  of  lymph  and  serum  into  its  sub- 
stance ;  a  blue  or  gray  iris  becomes  greenish,  whilst  a  rich 
brown  one  is  but  little  changed.  The  inflammatory  swell- 
ing of  the  iris  also  accounts  both  for  the  blurring  (muddi- 
ness)  of  its  beautifully  reticulated  structure,  and  for  the 
sluggishness  of  movement,  indicating  stiffness  of  its  tissue, 
noticed  in  the  early  period.  After  a  few  days,  lymph  is 
throAvn  out  at  one  or  more  spots  on  its  posterior  surface, 
and  still  further  hampers  its  movements  by  adhering  to  the 
lens-capsule;  and  most  cases  do  not  come  to  notice  till  some 
such  synechise  have  formed.  The  quantity  of  solid  exuda- 
tion, whether  on  the  hinder  surface  or  into  the  structure 
of  the  iris,  varies  much  ;  it  is  usually  greatest  in  syphilitic 
iritis,  when  distinct  nodules  of  pink  or  yellowish  color  are 
sometimes  seen  projecting  from  the  front  surface.  In  rare 
cases  pus  is  thrown  out  by  the  iris  into  the  aqueous,  and, 
sinking  down,  forms  a  hypopyon.  Firm  adhesions  to  the 
lens-capsule  may  be  present  without  much  evidence  of  ex- 
udation, into  the  structure  of  the  iris.  These  exudative 
changes  are  most  abundant  at  the  inner  ring  of  the  iris, 
where  its  capillary  vessels  are  far  the  most  numerous  (Fig. 
49). 

Apparent  discoloration  of  the  iris  is  also  due,  in  part,  to 
suspension  in  the  aqueous  humor  of  pus  or  blood-corpuscles, 
either  of  which  may  form  a  distinct  deposit  at  the  lowest 


136 


DISEASES     OF     THE     IRIS. 


part  of  the  anterior  chamber  (hypopyon,  hyphseraa). 
Sometimes  the  slightly  turbid  fluid  coagulates  into  a  gela- 
tinous mass,  which  almost  fills  the  chamber  ("  spongy  exu- 
dation "). 

The  tension  of  the  eyeball  is  often  a  little  increased  in 
acute  iritis ;  rarely  it  is  considerably  diminished,  and  in 
such  cases  there  are  generally  other  peculiarities. 

The  condition  of  the  pupil  alone  is  diagnostic  in  all  ex- 
cept very  mild  or  incipient  cases  of  iritis.  It  is  sluggish  or 

FIG.  49. 


Vessels  of  human  iris  artificially  injected;  capillaries  most  numerous  at 
pupillary  border,  and  next  at  ciliary  border. 

quite  inactive,  and  not  quite  round ;  it  is  also  rather  smaller 
than  its  fellow  (supposing  the  iritis  to  be  one-sided),  be- 
cause the  surface  of  the  iris  is  increased  (and  the  pupil, 
therefore,  encroached  on)  whenever  its  vessels  are  distended 
(p.  40).  Atropine  causes  it  to  dilate  between  the  synechise. 
These  synechise,  being  fixed,  appear  as  angular  projections 
when  the  iris  on  each  side  of  them  has  retracted.  If  there 


DISEASES     OP     THE     IKIS.  137 

be  only  one  adhesion,  it  will  merely  notch  the  pupil  at  one 
spot ;  if  the  adhesions  be  numerous,  the  pupil  will  be  cre- 
nated  or  irregular  (Fig.  50).  If  the  whole  pupillary  ring, 
or,  still  more,  if  the  entire  posterior  surface  of  the  iris,  be 
adherent,  scarcely  any  dilatation  will  be  effected ;  the 

FIG.  50. 


Posterior  synechiaj  causing  irregularity  of  pupil.     (Wecker  and  Jaeger.) 

former  condition  is  called  annular  or  circular  synechise, 
and  its  result  is  "  exclusion "  of  the  pupil;  the  latter  is 
known  as  total  posterior  synechia.  If  the  synechise  are  new 
and  the  lymph  soft,  the  repeated  use  of  atropine  will  cause 
them  to  give  way,  and  the  pupil  will  become  round,  but 
even  then  some  of  the  uveal  pigment,  which  is  easily  sep- 
arable from  the  posterior  surface  of  the  iris,  will  often  re- 
main behind,  glued  to  the  lens-capsule  by  a  little  lymph 
(Fig.  51)  ;  and  the  presence  of  one  or  more  such  spots  of 

FIG.  51. 


Spots  of  pigmqnt  and  lymph  at  seat  of  former  iritic  adhesions. 

brown  pigment  on  the  capsule  is  always  conclusive  proof 
of  present  or  of  past  iritis.  The  pupillary  area  itself  is 
often  blurred  or  even  quite  obscured  by  grayish  or  yellow- 
ish lymph,  which  spreads  over  it  from  the  iris.  The  iris 
may  be  inflamed  without  any  lymph  being  effused  from  its 

12* 


138  DISEASES    OF     THE     IRIS. 

hinder  surface,  and  then  the  pupil,  though  sluggish,  acting 
imperfectly  to  atropinc,  and  never  dilating  widely,  will 
present  no  posterior  syuechiso  nor  any  adhesion  of  pigment- 
spots  to  the  lens,  but  it  will  always  be  discolored  (serous 
iritis) ;  iritis  of  this  kind  often  occurs  with  ulceration  of 
the  cornea.  When  exudation  into  the  pupil  becomes  or- 
ganized, a  dense  white  membrane,  or  a  delicate  film  (often, 
however,  presenting  one  or  more  little  clear  holes),  is  formed 
over  the  pupil  ("  occlusion  of  the  pupil"^). 

Pain  referred  to  the  eyeball  and  to  the  parts  supplied  by 
the  first,  and  sometimes  by  the  second,  division  of  the  fifth 
nerve  is  a  common  accompaniment  of  iritis,  especially  in 
the  early  period  of  the  attack.  It  is  a  very  variable  symp- 
tom, and  gives  no  clue  to  the  amount  of  structural  change 
going  on  in  the  parts,  being  sometimes  quite  an  insignifi- 
cant feature  in  a  case  where  much  lymph  is  thrown  out. 
The  pain  is  seldom  constant,  but  comes  on  at  intervals,  is 
often  worst  at  night,  and  is  described  as  shooting,  throbbing, 
or  aching.  It  is  commonly  referred  to  the  temple  or  fore- 
head, as  well  as  to  the  eyeball,  but  sometimes  to  the  side  of 
the  nose  and  to  the  upper  teeth.  Photophobia  and  water- 
ing are  generally  proportionate  to  the  pain. 

The  duration  of  acute  iritis  varies  from  a  feAV  days  when 
mild  to  many  weeks  when  severe.  The  defect  of  sight  is 
proportionate  to  the  haziness  of  the  cornea,  aqueous,  and 
pupillary  space,  but  in  some  cases  is  increased  by  changes 
in  the  vitreous.  In  some  cases,  iritis  sets  in  very  grad- 
ually, causing  no  marked  congestion  or  pain,  but  slowly 
giving  rise  to  the  formation  of  tough  adhesions,  and  often 
to  the  growth  of  a  thin  membrane  over  the  pupillary  area; 
in  some  of  these  the  iris  becomes  thickened  and  tough,  and 
its  large  vessels  undergo  much  dilatation,  and  in  others 
keratitis  punctata  occurs  (see  Cyclitis,  p.  149;  Diseases  of 
Cornea,  p.  130;  and  Sympathetic  Ophthalmitis,  p.  153). 


DISEASES     OF     THE     IRIS.  139 

Results  of  iritis. — Such  of  the  results  as  are  permanent 
need  separate  notice.  Reference  has  been  made  to  the  ad- 
hesions, which  are  often  permanent,  and  to  the  spots  of 
uveal  pigment  on  the  lens-capsule,  which  are  always  so. 
Either  of  these  conditions  tells  a  tale  of  past  iritis  which 
is  often  a  valuable  aid  to  diagnosis.  A  blue  iris  which  has 
undergone  inflammation  may  remain  permanently  greenish. 
When  the  pupil  is  "  excluded "  or  "  occluded,"  the  re- 
mainder of  the  iris  being  free,  fluid  collects  in  the  poste- 
rior aqueous  chamber,  and  by  bulging  the  iris  forwards, 
and  diminishing  the  depth  of  the  anterior  chamber,  except 
at  its  centre,  gives  the  pupil  a  funnel-shape;  if  such  bulg- 
ing be  partial,  or  be  divided  by  bands  of  tough  membrane, 
the  iris  looks  cystic.  Secondary  glaucoma  is  likely  to  fol- 
low, and  the  tension  of  the  globe  should,  therefore,  be  care- 
fully noted  whenever  this  bulging  is  present.  "  Total  pos- 
terior synechia"  always  shows  a  severe  though  often  a 
chronic  iritis;  it  often  signifies  deep-seated  disease,  and  is 
often  followed  by  opacity  of  the  lens  (secondary  cataract). 
Relapses  of  iritis  are  believed  to  be  induced  by  the  pres- 
ence of  synechise,  even  Avhen  there  is  no  protrusion  of  the 
iris  by  fluid;  but  their  influence  in  this  direction  has  prob- 
ably been  much  overrated. 

The  following  are  the  most  important  points  as  to  the 
causes  of  iritis,  and  the  chief  clinical  differences  between 
the  several  forms. 

CONSTITUTIONAL  CAUSES.  Syphilis. — The  iritis  is  acute; 
it  shows  a  great  tendency  to  effusion  of  lymph  and  forma- 
tion of  vascular  nodules  (plastic  iritis),  and  the  nodules, 
when  very  large,  may  even  suppurate;  it  is  very  often  sym- 
metrical.1 But  asymmetry  and  absence  of  lymph-nodules 
are  common.  It  occurs  only  in  secondary  syphilis  (either 
acquired  or  inherited),  and  seldom  relapses.  It  is  to  be 

1  In  two-thirds  of  the  cases. 


140  DISEASES     OF     THE     IRIS. 

carefully  distinguished  from  the  iritis  which  often  compli- 
cates syphilitic  keratitis  (p.  125). 

Rheumatism  is  the  cause  of  most  cases  of  relapsing  un- 
symmetrical  iritis ;  there  is  but  little  tendency  to  effusion 
of  lymph,  and  nodules  are  never  formed,  but  there  is  occa- 
sionally fluid  hypopyon  (pp.  117  and  135);  the  congestion 
and  pain  are  often  more  severe  than  in  syphilitic  iritis.  A 
single  attack  is  rarely  symmetrical,  though  both  eyes  com- 
monly suffer  by  turns.  It  relapses  at  intervals  of  months 
or  years.  Even  repeated  attacks  sometimes  result  in  but 
little  damage  to  sight.  Gout  is  apparently  a  cause  of  some 
cases  of  both  acute  and  insidious  chronic  iritis.  It  is  per- 
haps doubtful  whether  the  gout  or  the  chronic  rheumatism 
from  which  the  same  patients  sometimes  suffer  is  the  cause 
of  the  iritis.  In  its  tendency  to  relapse  and  to  affect  only 
one  eye  at  a  time  gouty  resembles  rheumatic  iritis.  The 
children  of  gouty  parents  are  occasionally  liable  to  a  very 
insidious  and  destructive  form  of  chronic  iritis,  with  dis- 
ease of  the  vitreous,  keratitis  punctata,  and  glaucoma  (p. 
150)  (see  also  Chapter  "Etiology"). 

Chronic  iritis  (plastic  irido-choroiditis,  see  also  p.  149). — 
In  a  few  cases  symmetrical  iritis,  of  a  chronic,  progressive 
and  destructive  character,  is  complicated  with  choroiditis, 
disease  of  vitreous  and  secondary  cataract.  These  cases, 
for  which  it  is  at  present  impossible  to  assign  any  cause 
either  general  or  local,  are  chiefly  seen  in  young  adults, 
and,  I  think,  oftenest  in  women. 

Sympathetic  iritis. — See  Sympathetic  Ophthalmitis. 

LOCAL  CAUSES.  Injuries. — Perforating  wounds  of  the 
eyeball,  particularly  if  irregular,  contused,  and  compli- 
cated with  wound  of  the  lens,  are  often  followed  by  iritis. 
Perforating  wounds  are  more  likely  to  be  followed  by  iritis 
in  old  than  in  young  persons.  If  the  corneal  wound  sup- 
purate or  become  much  infiltrated  the  iritis  is  likely  to  be 
suppurative,  and  the  inflammation  to  spread  to  the  deeper 


DISEASES     OF     THE     IRIS.  141 

structures .  and  cause  destructive  panophthalmitis.  Iritis 
may  follow  a  wound  of  the  leus-capsule  without  wound  of" 
the  iris,  and  with  only  a  mere  puncture  of  the  cornea. 
Examples  of  traumatic  iritis  from  these  several  causes  are 
seen  after  the  various  operations  for  cataract.  The  iritis 
(or  more  correctly  irido-cyclitis)  following  extraction  of 
senile  cataract  is  often  prolonged,  attended  by  chemosis, 
much  congestion,  and  the  formation  of  tough  membrane 
behind  the  iris  (see  "Cataract").  Iritis  may  also  follow 
superficial  wounds  and  abrasions  of  the  cornea,  or  direct 
blows  on  the  eye ;  but  it  is  of  great  importance,  whenever 
the  question  of  injury  comes  in,  to  ascertain  whether  or  not 
there  has  been  a  perforating  wound.  Iritis  often  accompa- 
nies ulcers  and  other  inflammations  of  the  cornea  especially 
when  deep,  or  complicated  with  hypopyon,  or  occurring  in 
elderly  persons.  Iritis  may  be  secondary  to  deep-seated 
disease  or  tumor  in  the  eye. 

TREATMENT. — (1)  In  every  case  where  iritis  is  present 
atropine  is  to  be  used  often  and  continuously,  in  order  to 
break  down  adhesions  which  have  formed,  and  to  allow  any 
lymph  subsequently  formed  to  be  thrown  out  beyond  the 
area  of  the  ordinary  pupil.  A  strong  solution  (four  grains 
of  sulphate  of  atropine  to  one  ounce  of  distilled  water)  is 
to  be  dropped  into  the  conjunctival  sac  every  hour  in  the 
early  period.  In  many  cases  the  synechise  are,  when  first 
seen,  already  so  tough  that  the  atropine  has  no  effect  on 
them ;  but  even  then  it  may  still  prevent  new  ones  forming 
on  the  same  circle.  Moreover,  the  pupil  when  kept  widely 
dilated  is  less  likely  to  be  covered  over  by  lymph  or  organ- 
ized membrane  from  the  iris  than  if  contracted.  Atropine 
also  diminishes  congestion  and  greatly  relieves  pain  in 
iritis. 

(2)  If  there  be  severe  pain  with  much  congestion,  three 
or  four  leeches  should  be  applied  to  the  temple,  to  the 
malar  eminence,  or  to  the  side  of  the  nose.  They  may  be 


142  DISEASES     OF     THE     IRIS. 

repeated  daily,  in  the  same  or  smaller  numbers,  with  ad- 
vantage for  several  days,  if  necessary ;  or  after  one  leech- 
ing repeated  blistering  may  be  substituted.  Some  surgeons 
use  opiates  instead  of,  or  in  addition  to,  leeches.  Leeches 
occasionally  increase  the  pain.  Severe  pain  in  iritis  can 
nearly  always  be  quickly  relieved  by  artificial  heat;  either 
fomentations  or  dry  heat,  as  hot  as  can  be  borne,  to  the 
eyelids.  To  apply  dry  heat,  take  a  bunch  of  cotton-wool 
the  size  of  two  fists,  hold  it  to  the  fire,  or  against  a  tin  pot 
full  of  boiling  water,  till  quite  hot,  and  apply  it  to  the  lids ; 
have  another  piece  ready  and  change  as  soon  as  the  first 
gets  cool ;  continue  this  for  twenty  minutes  or  more,  and 
repeat  it  several  times  a  day.1  Paracentesis  of  the  ante- 
rior chamber  should  be  resorted  to  in  severe  iritis  if  the 
aqueous  tumor  remain  turbid  after  a  few  days  of  other 
treatment;  the  wound  is  to  be  reopened  daily  until  there  is 
marked  improvement. 

(3)  Kest  of  the  eye  is  very  important.     Many  a  case  is 
lengthened  out  and  many  a  relapse  after  partial  cure  is 
brought  on  by  the  patient  continuing  at,  or  returning  too 
soon  to,  work.    It  is  not,  in  most  cases,  necessary  to  remain 
in  a  perfectly  dark  room ;  to  wear  a  shade  in  a  room  with 
the  blinds  down  is  generally  enough,  provided  that  no 
attempt  be  made  to  use  the  eyes.     Work  should  not  be  re- 
sumed till  at  least  a  week  after  all  congestion  has  gone  off. 

(4)  Cold  draughts  of  air  on  the  eye  and  all  causes  of 
"  catching  cold  "  are  to  be  very  carefully  avoided,  by  keep- 
ing the  eye  warmly  tied  up  with  a  large  pad  of  cotton-wool. 

(5)  The  cause  of  the  disease  is  to  be  treated,  and  into 
this  careful  inquiry  should  always  be  made.     If  the  iritis 
be  syphilitic,  treatment  for  secondary  syphilis  is  proper, 
mercury  being  given  to  very  slight  salivation  for  several 

1  I  owe  my  knowledge  of  the  great  value  of  dry  heat,  so  ap- 
plied, to  Mr.  Liebreich. 


DISEASES     OP     THE     IRIS.  14-3 

months,  even  though  all  the  active  eye  symptoms  quickly 
pass  off.  The  rheumatic  and  gouty  varieties  are  less  defi- 
nitely under  the  influence  of  internal  remedies ;  iodide  of 
potassium,  alkalies,  and  colchicum  certainly  appear  to 
exert  a  good  effect  in  some  cases ;  when  the  pain  is  severe, 
tincture  of  aconite  is  sometimes  markedly  useful ;  mercury 
is  seldom  needed,  but  in  protracted  and  severe  cases  it  may 
sometimes  be  used  with  advantage.  It  is  sometimes  ad- 
visable to  combine  quinine  with  the  mercury  in  syphilis, 
or  to  give  it  in  addition  to  other  remedies  in  rheumatic 
cases. 

(6)  As  a  rule,  no  stimulants  are  to  be  allowed,  and  the 
bowels  should  be  kept  well  open. 

(7)  Iridectomy  is  needed  for  cases  of  severe  iritis  where 
judicious  local  and  internal  treatment  have  been  carefully 
tried  for  some  weeks  without  marked  relief  to  the  inflamma- 
tory symptoms,  and  whether  or  not  there  be  increased  ten- 
sion.    It  is  chiefly  in  cases  of  constitutional  origin,  either 
syphilitic  or  rheumatic,  and  in   the   iritis   accompanying 
ulcers  of  the  cornea,  that  it  is  necessary.    It  is  not  applica- 
ble to  sympathetic  iritis,  nor  to  iritis  after  cataract  extrac- 
tion.    In  reference  to  iridectomy,  it  is  to  be  borne  in  mind 
that  unless  necessary  it  is  injurious,  by  producing  an  en- 
larged and  irregular  pupil  through  which,  owing  to  spheri- 
cal aberration,  the  patient  will  often    not  see  so  well  as 
through  the  natural  pupil,  even  though  this  be  partially  ob- 
structed.   The  effect  cf  the  operation  in  staying  and  abating 
the  inflammation  is  very  marked  in  some  cases,  but,  in  order 
to  be  sure  that  the  effect  is  due  to  the  operation,  we  must 
have  first  tried  fairly  the  other  means  of  cure.     Indeed,  in 
regard  to  all  methods  of  local  treatment,  we  must  bear  in 
mind  that  acute  iritis  occurs  in  all  degrees  of  severity,  and 
that  the  mildest  cases  often  need  only  atropine  and  rest. 

Traumatic  iritis,  in  a  very  early,  stage  is  best  combated 
by  continuous  cold  applied  by  means  of  pieces  of  lint  wetted 


144  DISEASES     OE     THE     IRIS. 

in  iced  water  or  on  a  block  of  ice,  and  laid  upon  the  lids  ; 
and  by  leeches.  Cold  is  not  to  be  used  to  any  other  form  of 
iritis. 

Congenital  irideremia  (absence  of  iris)  is  occasionally 
seen,  and  is  often  associated  with  other  congenital  defects 
of  the  eye. 

Coloboma  of  the  iris  (congenital  cleft  in  the  iris)  gives 
the  effect  of  a  very  regularly  made  iridectomy.  It  is  al- 
ways downwards  or  slightly  down-in,  and  usually,  but  not 
always,  symmetrical.  There  are  many  varieties  in  degree, 
and  sometimes  there  is  nothing  more  than  a  sort  of  line  or 
seam  in  the  iris.  It  often  occurs  without  coloboma  of  the 
choroid. 

Persistent  remains  of  the  pupillary  membrane  have 
sometimes  to  be  distinguished  from  iritic  adhesions.  They 
occur  in  the  form  of  thin  shreds  or  loops  of  tissue,  in  color 
resembling  the  iris,  to  the  anterior  surface  of  which,  close 
to  its  pupillary  border,  they  are  attached.  They  are  longer 
and  slenderer  than  posterior  synechise,  and  are  not  attached 
to  the  lens-capsule.1  In  one  remarkable  instance  I  saw 
well-marked  remains  of  this  membrane  complicated  with 
equally  unequivocal  iritic  adhesions  in  a  case  of  acute  iritis 
in  a  man. 

1  "When  remains  of  pupillary  membrane  are  complicated  with 
old  iritic  adhesions  in  children,  there  has  probably  been  intra- 
uterine  iritis. 


DISEASES    OF     THE    CILIARY     REGION.      145 


CHAPTER   X. 

DISEASES    OF    THE    CILIARY    REGION. 

THIS  chapter  is  intended  to  include  cases  in  which  the 
ciliarv  body  itself,  or  the  corresponding  part  of  the  scle- 
rotic, or  the  episcleral  tissue,  is  the  sole  seat,  or  at  least  the 
headquarters  of  inflammation.  The  abundance  of  vessels 
and  nerves  in  the  ciliary  body,  and  the  importance  of  its 
nutritive  relations  to  the  surrounding  parts  prepare  us  to 
find  that  many  of  the  morbid  processes  of  the  ciliary  region 
show  a  strong  tendency  to  spread,  according  to  their  pre- 
cise position  and  depth,  to  the  cornea,  iris,  or  vitreous,  and 
by  influencing  the  nutrition  of  the  lens  to  cause  secondary 
cataract.  Although  alike  on  pathological  and  clinical 
grounds  it  is  necessary  to  subdivide  the  class  into  groups, 
we  may  observe  that  in  some  of  their  more  obvious  and 
important  characters  all  the  diseases  of  this  part  show  a 
general  agreement ;  thus  all  of  them  are  protracted  and 
liable  to  relapse,  and  in  all  there  is  a  marked  tendency  to 
patchiness,  the  morbid  process  being  most  intense  in  certain 
spots  of  the  ciliary  zone,  or  even  occurring  in  quite  dis- 
crete patches.  It  is  convenient  to  make  three  principal 
clinical  groups,  the  differences  between  which  are  ac- 
counted for  to  a  great  extent  by  the  depth  of  the  tissue 
chiefly  implicated.  The  most  superficial  may  be  taken  first. 
(1)  Episcleritis  (more  correctly  SclerotHis)  is  the  name 
given  to  one  or  more  large  patches  of  congestion,  with 
some  elevation  of  the  conjunctiva  from  thickening  of  the 
subjacent  tissues,  in  the  ciliary  jegion.  The  congestion 
generally  affects  the  conjunctival  as  well  as  the  deeper 

18 


146      DISEASES    OF    THE    CILIARY    KEGION. 

vessels,  and  the  yellowish  color  of  the  exudation  tones  the 
bright  blood-red  down  to  a  more  or  less  rusty  tinge,  which 
is  especially  striking  at  the  centre  of  the  patch,  where  the 
thickening  is  greatest.  The  latter  varies  in  amount,  but 
seldom  causes  more  than  a  low,  Avidely  spread  mound  of 
swelling. 

Episcleritis  is  a  rather  rare  disease.  It  occurs  chiefly  on 
the  exposed  parts  of  the  ciliary  region,  and  especially  near 
the  outer  canthus,  but  the  patches  may  occur  at  any  part 
of  the  circle;  and  exceptionally  the  inflammation  is  diffused 
over  a  much  wider  area  than  the  ciliary  zone,  extending 
back  out  of  view.  The  iris  is  often  a  little  discolored  and 
the  pupil  sluggish,  but  actual  iritis  is  rare.  There  is  often 
much  aching  pain.  The  disease  is  subacute,  reaching  its 
acme  in  not  less  than  two  or  three  weeks,  and  requiring  a 
much  longer  time  before  absorption  is  complete.  Fresh 
patches  are  apt  to  spring  up  while  old  ones  are  declining, 
and  so  the  disease  may  last  for  months ;  indeed,  relapses 
sooner  or  later  (in  fresh  spots)  are  the  rule.  It  usually 
affects  only  one  eye  at  a  time,  but  both  often  suffer  sooner 
or  later.  After  the  congestion  and  thickening  have  dis- 
appeared a  patch  of  the  underlying  sclerotic,  of  rather 
smaller  size,  is  generally  seen  to  be  dusky  as  if  stained ;  it 
is  doubtful  whether  such  patches  represent  thinning  of  the 
sclerotic  from  atrophy  or  only  staining ;  it  is  but  seldom 
that  they  show  any  tendency  to  bulge  as  if  thinned. 

In  rare  cases  the  exudation  is  much  more  abundant, 
and  a  large  hemispherical  swelling  is  formed,  which  may 
even  contain  pus  ;  such  cases  pass  by  gradations  into  con- 
junctival  phlyctenulse,  and  are  generally  seen  in  chil- 
dren (compare  p.  116). 

Episcleritis  is  seldom  seen  except  in  adults,  and  is  com- 
moner in  men  than  in  women.  It  is  commonest  on  the 
exposed  parts  of  the  globe,  and  inquiry  often  shows  that 
the  sufferer  is,  either  from  occupation  or  temperament,  par- 


DISEASES    OF     THE     CILIARY    REGION.       147 

ticularly  liable  to  be  affected  by  exposure  to  cold  or  by 
changes  of  temperature ;  some  are  decidedly  rheumatic. 
Similar  patches,  but  of  a  brownish,  rather  translucent  ap- 
pearance, are  occasionally  caused  by  tertiary  syphilis, 
acquired  or  inherited  ("  gummatous  sclerotitis"}. 

In  the  treatment,  protection  by  a  warm  bandage,  rest, 
the  yellow  ointment,  the  use  of  repeated  blisters,  and  local 
stimulation  of  the  swelling,  are  generally  the  most  effica- 
cious. Atropine  is  very  useful  in  allaying  pain.  Internal 
remedies  seldom  seem  to  exert  much  influence  except  in 
syphilitic  cases. 

Lately  systematic  kneading  of  the  eye  through  the  closed 
lids  (massage),  and  also  scraping  away  the  exudation  with 
a  sharp  spoon,  after  turning  back  the  conjunctiva,  have 
been  highly  spoken  of,  and  are  certainly  worth  trial. 

(2)  Sclero-keratitis  and  sclero-iritis  ("scrofulous  scle- 
rotitis,"  "  anterior  choroiditis").  A  more  deeply  seated, 
very  persistent,  or  relapsing  subacute  inflammation,  char- 
acterized by  congestion  of  a  violet  tinge  (deep  scleral  con- 
gestion, p.  27,  2),  being  abruptly  limited  to  the  ciliary 
zone,  and  affecting  some  parts  of  the  zone  more  than  others 
(tendency  to  patchiness).  Early  in  the  case  there  is  a 
slight  degree  of  bulging  of  the  affected  part,  due  partly  to 
thickening ;  whilst  patches  of. cloudy  opacity,  which  may 
or  may  not  ulcerate,  appear  in  the  cornea  close  to  its  mar- 
gin. Later  on,  iritis  generally  occurs.  Pain  and  photo- 
phobia are  often  severe.  After  a  varying  interval,  always 
weeks,  more  often  months,  the  symptoms  recede.  At  the 
focus  of  greatest  congestion,  or  it  may  be  around  the  entire 
zone,  the  sclerotic  is  left  of  a  dusky  color,  sometimes  inter- 
spersed with  little  yellowish  patches,  and  permanent  hazi- 
ness of  the  most  affected  parts  of  the  cornea  remains.  The 
disease  is  almost  certain  to  relapse  sooner  or  later ;  or  a 
succession  of  fresh  inflammatory  foci  follow  each  other 
without  any  intervals  of  real  recovery,  the  whole  process 


148       DISEASES    OF     THE     CILIAKY    HEGION. 

extending  over  many  months.  After  each  attack  more 
haze  of  cornea  and  fresh  iritic  adhesions  are  left.  The 
sclerotic,  in  bad  cases  of  some  years'  standing,  becomes 
much  stained,  and  bulges  very  considerably  (ciliary  or  an- 
terior staphyloma),  and  the  cornea  becomes  both  opaque 
and  altered  in  curve ;  the  eye  is  then  useless,  though  but 
seldom  liable  to  further  active  symptoms. 

The  characteristic  appearance  of  an  eye  which  has  been 
moderately  affected,  is  the  dusky  color  of  the  sclerotic  and 
the  irregular  patchy  opacity  of  the  cornea  (Fig.  52),  the 
opacities  being  often  continuous  \vith  the  sclerotic.  The 
disease  does  not  occur  in  children,  nor  does  it  begin  late  in 
life;  most  of  the  patients  are  young  or  middle-aged  adults, 

FIG.  52. 


Relapsing  selero-keratitis  (from  nature). 

and,  unlike  the  former  variety,  most  are  women.  It  is  not 
associated  with  any  special  diathesis  or  dyscrasia,  but  gen- 
erally goes  along  with  a  feeble  circulation  and  liability  to 
"  catch  cold ;"  in  some  cases  there  is  a  definite  family  history 
of  scrofula  or  of  phthisis.  Predisposed  persons  are  more 
likely  to  suffer  in  cold  weather,  or  after  change  to  a  colder 
or  damper  climate,  or  after  any  cause  of  exhaustion,  such 
as  suckling. 

TREATMENT  is  at  best  but  palliative.  Local  stimulation 
by  yellow  ointment  or  calomel  is  very  useful  iu  some  cases, 
particularly  those  which  verge  towards  the  phlyctenular 


V 

DISEASES     OF     THE     CILIARY    REGION.       149 

type.  In  the  early  stages,  especially  when  the  congestion 
is  very  violent  and  altogether  subconjunctival,  atropine  often 
gives  relief,  and  it  is,  of  course,  useful  for  the  iritis.  Re- 
peated blistering  is  also  to  be  tried,  though  not  all  cases 
are  benefited  by  it.  I  have  not  seen  much  benefit  from 
setons.  Warm,  dry  applications  to  the  lids  are,  as  a 
rule,  better  than  cold.  Mercury,  in  small  and  long-con- 
tinued dcses,  is  certainly  valuable  when  the  patient  is  not 
anaemic  and  feeble,  but  it  is  to  be  combined  with  cod-liver 
oil  and  iron.  Protection  from  cold  and  bright  light  by 
''goggles"  is  a  very  important  measure,  both  during  the 
attacks  and  in  the  intervals  between  them.  There  is  no 
rule  as  to  symmetry  ;  both  eyes  often  suffer  sooner  or  later, 
but  sometimes  one  escapes  whilst  the  other  is  attacked  re- 
peatedly. Transition  forms  occur  between  this  disease  and 
episcleritis. 

(3)  Cyclitis  with  disease  of  vitreous  and  keratitis  punc- 
tata  (chronic  serous  irido-choroiditis).  A  small  but  im- 
portant series  of  cases,  in  which  there  is  congestion  like 
that  attending  mild  iritis,  and  dulness  of  sight,  but  usually 
with  no  pain  or  photophobia.  Flocculi  are  found  in  the 
anterior  part  of  the  vitreous,  or  numerous  small  dots  of 
deposit  are  seen  on  the  posterior  surface  of  the  cornea 
(keratitis  punctata,  Fig.  47) ;  the  anterior  chamber  is  often 
too  deep,  and  insidious  iritis  usually  follows.  Patches  of 
recent  choroiditis  are  often  to  be  seen  at  the  fundus. 
Persistence  and  liability  to  relapse  are  features  as  marked 
here  as  in  the  other  members  of  the  cyclitic  group.  The 
final  condition  turns  very  much  on  the  extent  of  the  iritic 
adhesions,  for  when  the  synechice  are  numerous  and  tough, 
and  the  iris  is  much  altered  in  structure,  secondary  glau- 
coma may  arise  (p.  139)  or  the  pupil  be  blocked  by  iritic 
membrane.  "When  seen  quite  early,  such  a  case  will  prob- 
ably be  diagnosed  as  "serous  iritis"  or  as  "ciliary  con- 
gestion," unless  carefully  examined,  for  the  pupil  is  gen- 

1?,* 


150       DISEASES     OF     THE    CILIAIIY    REGION. 

erally  free  in  all  parts,  or  shows,  at  most,  one  or  two  ad- 
hesions when  atropine  is  used;  glaucomatous  symptoms, 
however,  sometimes  develop  early  in  the  disease,  before 
iritic  adhesions  have  formed.  In  a  few  cases  the  punctate 
deposits  on  the  back  of  the  cornea  constitute  almost  the 
only  objective  change  (simple  keratitis  punctata),  but  these 
are  very  rare  (p.  131)  (compare  Chronic  Iritis,  p.  140). 

The  cases  occur  always  in  adolescents  or  young  adults, 
and  the  disease  is  always  sooner  or  later  symmetrical. 
Many  mild  cases  recover  perfectly,  and  in  others  a  good 
result  is  finally  achieved.  In  respect  to  cause,  there  is 
strong  reason  to  believe  that  many  of  these  cases  are  the 
result  of  gout  in  a  previous  generation,  the  patient  himself 
never  having  had  the  disease  (Hutchinson).  The  disease 
seems  often  to  be  excited  in  predisposed  persons  by  pro- 
longed overwork  or  anxiety,  combined  with  underfeeding, 
or,  what  comes  to  the  same  thing,  defective  assimilation  ; 
the  patients  often  describe  themselves  as,  or  are  obviously, 
delicate.  On  the  other  hand,  in  some  of  the  worst  cases, 
leading  to  secondary  cataract  and  ultimately  to  shrinking 
of  the  eyes  (see  Chronic  Iritis,  p.  140),  the  patient  appears 
to  be,  from  first  to  last,  in  good  health,  and  free  from  any 
ascertainable  morbid  diathesis. 

In  the  treatment,  prolonged  use  of  atropine  and  rest  of 
the  eyes  arc  the  most  important  local  measures.  In  certain 
cases  iridectomy  is  necessary.  Small  doses  of  iodide  of 
potassium  and  mercury  appear  to  be  useful  in  the  earlier 
stages,  given  with  proper  precautions,  and  accompanied  by 
iron,  cod-liver  oil,  and  sometimes  quinine  or  bitters.  Change 
of  climate  would  probably  often  be  beneficial.  In  the 
worst  cases,  where  the  changes  are  very  like  those  resulting 
from  sympathetic  ophthalmitis,  no  treatment  seems  to  have 
any  effect. 

Cases  of  acute  inflammation  are  occasionally  seen  in 
which  most  of  the  symptoms  resemble  those  of  acute  iritis, 


DISEASES    OF    THE     CILIARY    REGION.       151 

but  with  the  iris  so  little  affected  that  it  is  evidently  not 
the  headquarters  of  the  morbid  action.  The  tension  may 
be  much  reduced,  whilst  repeated  aud  rapid  variations, 
both  in  sight  and  objective  symptoms,  occur.  The  term 
"idiopathic  phthisis  bulbi"  has  been  applied  to  some  of 
these.  Again,  some  cases  of  syphilitic  inflammation,  which 
are  classed  as  syphilitic  "  iritis,"  might  more  correctly  be 
called  "  cyclitis."  In  some  cases  of  heredito-syphilitic  kera- 
titis  there  is  much  cyclitic  complication  (p.  128),  and  these 
are  always  difficult  to  treat. 

Plastic  or,  more  rarely,  purulent  inflammation  of  the 
ciliary  body,  following  injury,  is  the  usual  starting-point  of 
the  changes  which  set  up  sympathetic  inflammation  of  the 
fellow  eye ;  and  the  changes  in  the  sympathizing  eye  gen- 
erally begin  also  in  the  ciliary  body,  quickly  spreading 
forwards  to  the  iris,  and  backwards  to  the  choroid,  vitreous, 
and  retina.  The  outset  of  this  traumatic  cyclitis  (jpan&ph- 
thalmitu)  is  signalized  by  ciliary  congestion,  pain,  and 
marked  tenderness  to  palpation ;  there  is  often  lowered 
tension  and  iritis.  If  the  lens  be  transparent,  a  yellow  or 
greenish  reflection  is,  after  a  few  days,  often  seen  from 
behind  it,  indicating  the  presence  of  pus  in  the  vitreous 
humor. 

SYMPATHETIC    IRRITATION    AND    SYMPATHETIC 
OPIITHALMITIS. 

Certain  morbid  changes  in  one  eye  may  set  up  functional 
disturbance  and  destructive  inflammation  in  its  fellow. 
The  term  sympathetic  irritation  is  given  to  the  former,  and 
sympathetic  ophthalmitis  (or  ophthalmia)  to  the  latter.  They 
may  be  combined,  but  often  occur  separately,  and  it  is  very 
important  to  distinguish  between  them. 

Although  at  present  the  exact  nature  of  the  process 
which  causes  sympathetic  inflammation  is  unknown,  and 


152      DISEASES     OF    THE     CILIARY    REGION. 

though  its  path  has  not  been  fully  traced  out,  it  is  certain 
(1)  that  the  change  starts  from  the  region  most  richly  sup- 
plied by  branches  of  the  ciliary  nerves  (composed  of  fibres 
from  the  fifth,  sympathetic,  and  third),  viz.,  the  ciliary 
body  and  iris ;  (2)  that  its  first  effects  are  generally  seen  in 
the  same  part  of  the  sympathizing  eye;  (3)  that  the  exciting 
eye  has  nearly  always  been  wounded,  and  in  its  anterior 
part ;  and  that  decided  plastic  inflammation  of  its  uveal 
tract  is  always  present ;  (4)  that  inflammatory  changes 
have  in  some  cases  been  found  in  the  ciliary  nerves  and 
optic  nerve  of  the  exciting  eye. 

The  morbid  influence  has  of  late  years  been  generally 
believed  to  pass  along  the  ciliary  nerves,  but  the  earlier 
hypothesis  of  transmission  along  the  optic  nerve  has  re- 
cently been  revived,  and  further  the  bloodvessels,  lym- 
phatics, and  even  the  blood  itself  are  at  the  present  time 
claimed  by  different  authors  as  probable  channels.  The 
histology  of  the  subject  needs  to  be  gone  over  again  with 
the  most  modern  methods. 

In  almost  every  case  sympathetic  inflammation  is  set  up 
by  a  perforating  wound,  either  accidental  or  operative,  in 
the  ciliary  region  of  the  other  eye,  i.  e.,  within  a  zone, 
nearly  a  quarter  of  an  inch  wide,  surrounding  the  cornea. 
The  risk  attending  a  wound  in  this  "  dangerous  zone "  is 
increased  if  it  be  lacerated,  or  heal  slowly,  or  if  the  iris  or 
ciliary  body  be  engaged  between  the  lips  of  the  sclerotic, 
or  if  the  eye  contain  a  foreign  body ;  under  all  conditions, 
indeed,  which  make  the  occurrence  of  plastic  or  purulent 
cyclitis  probable.  Sympathetic  inflammation  may  also  be 
caused  by  perforating  ulceration  of  the  cornea  with  ante- 
rior synechia;  and  by  an  eye  containing  a  tumor,  though 
probably  not  unless  the  eye  has  been  operated  upon.  A 
foreign  body  lodged  in  the  eye,  whether  the  wound  be  in 
the  ciliary  region  or  not,  is  always  a  possible  source  of 
sympathetic  mischief;  and  a  wound  entirely  corneal,  if 


DISEASES     OF     THE    CILIAKY    REGION.       153 

complicated  by  a  large  anterior  synechia  with  dragging  on 
the  ciliary  body,  may  also  occasion  it. 

Symptoms  in  the  exciting  eye. — The  exciting  eye  gen- 
erally shows  ciliary  congestion  and  photophobia,  and  often 
suffers  neuralgic  pain  when  it  is  causing  sympathetic  irri- 
tation. Iritis  is  always  present  in  an  eye  which  is  causing 
sympathetic  inflammation;  but  the  iritis  is  often  painless 
and  without  noticeable  congestion,  and  thus  may  easily  be 
overlooked.  It  is  especially  important  to  remember  that 
the  exciting  eye,  though  its  sight  is  always  damaged,  need 
not  be  blind,  and  that,  under  certain  circumstances,  it  may 
in  the  end  be  the  better  eye  of  the  two. 

Symptoms  in  the  sympathizing  eye.  a.  Sympathetic  Irri- 
tation.— The  eye  is,  in  common  speech,  "weak"  or  "irrita- 
ble." It  is  intolerant  of  light,  and  easily  flushes  and 
waters  if  exposed  to  bright  light  or  if  much  used ;  the  ac- 
commodation is  weakened  or  irritable,  so  that  continued 
vision  for  near  objects  is  painful  or  even  impossible,  and 
the  ciliary  muscle  seems  liable  to  give  way  suddenly  for  a 
short  time,  the  patient  complaining  that  near  objects  now 
and  then  suddenly  become  misty  for  a  while.  Temporary 
darkening  of  sight,  indicating  suspension  of  retinal  func- 
tion, is  said  to  occur,  whilst  other  cases  show  a  considerable 
and  more  lasting  defect  of  sight  without  ophthalmoscopic 
changes,  and  of  obscure  causation.  Neuralgic  pains  re- 
ferred to  the  eye  and  side  of  the  head  are  also  common. 
Such  attacks  may  occur  again  and  again  in  varying  sever- 
ity, lasting  for  days  or  weeks,  and  finally  ceasing  without 
ever  passing  on  to  structural  change.  Sympathetic  irrita- 
tion is  always,  and  as  a  rule  promptly,  cured  by  removal 
of  the  exciting  eye ;  but  occasionally  the  symptoms  persist 
for  some  time  afterwards. 

b.  Sympathetic  Inflammation  (^Ophtlialmitis}. — The  disease 
may  arise  out  of  an  attack  of  "irritation,"  but  more  com- 
monly sets  in  without  any  such  warniug.  It  may  be  acute 


154      DISEASES    OF     THE    CILIARY    REGION. 

and  severe,  or  so  insidious  as  to  escape  the  notice  of  the 
patient  until  -well  advanced.  It  is  in  all  cases  a  prolonged 
and  a  relapsing  disease ;  -when  once  started  it  is  self-main- 
taining, and  its  course  usually  extends  over  many  months, 
or  even  a  year  or  two.  In  mild  cases  a  good  recovery 
eventually  takes  place,  but  in  a  large  majority  the  eye  be- 
comes blind.  The  disease  is  essentially  an  irido-cyclitis  or 
irido-choroiditis,  the  external  signs  being  those  of  iritis  with 
rapid  formation  of  tough  and  extensive  synechise.  Its 
chief  early  peculiarities  are  a  great  liability  to  dotted  de- 
posits on  the  back  of  the  cornea  (p.  130),  a  dusky  tint  of 
ciliary  congestion  with  marked  engorgement  of  the  large 
vessels  which  perforate  the  sclerotic  in  the  ciliary  region 
(as  in  glaucoma),  and  marked  thickening  and  muddiness 
of  the  iris,  the  anterior  chamber  becoming  shallow;  we 
must  add  that  there  is  frequently  tenderness  on  pressure  in 
the  ciliary  region.  If  the  pupil  allows  of  ophthalmoscopic 
examination,  we  shall  find  the  vitreous  clouded  by  floating 
opacities,  and  there  may  be  ueuro-retinitis.  In  acute  and 
severe  cases  the  congestion  is  intense,  there  is  severe  pain, 
photophobia,  and  tenderness  on  pressure,  and  the  iris,  be- 
sides being  thick,  is  changed  in  color  to  a  peculiar  buff  or 
yellowish-brown,  and  shows  numerous  enlarged  bloodves- 
sels ("plastic"  form).  Attacks  of  intense  neuralgia  of  the 
fifth  nerve  characterize  some  cases.  In  cases  of  all  degrees, 
the  tension  is  often  increased,  the  eye  becoming  decidedly 
glaucomatous  for  a  longer  or  shorter  time.  The  lens  often 
suffers,  showing  many  small  dotted  opacities,  and  eventu- 
ally becoming  opaque.  In  the  worst  cases  the  eye  finally 
shrinks,  but  in  many  a  prolonged  glaucomatous  state  is 
established,  with  slight  thinning  and  bulging  of  the  scle- 
rotic in  front,  total  posterior  synechia,  and  secondary  cata- 
ract. In  the  mildest  cases  (the  so-called  "  serous"  form),  the 
disease  never  goes  beyond  a  chronic  iritis  with  punctate 
keratitis  and  disease  of  the  vitreous. 


DISEASES    OF     THE    CILIARY    REGION.       155 

Sympathetic  ophthalmitis  generally  begins  about  two  or 
three  months  after  the  injury  or  other  cause  of  mischief  in 
the  exciting  eye;  seldom,  if  ever,  sooner  than  three  weeks, 
i.  e.,  not  until  time  has  elapsed  for  well-marked  inflamma- 
tory changes  to  occur  at  the  seat  of  injury.  On  the  other 
hand,  the  disease  may  set  in  at  any  length  of  time,  even 
many  years,  after  the  injury  or  other  disease  of  the  ex- 
citing eye,  particularly  if  the  latter  contain  a  foreign  body. 
It  occurs  at  all  ages,  but  children  are  considered  to  be  more 
liable  than  adults.  Distinct  inflammatory  changes  are  al- 
ways present  in  the  exciting  eye,  but,  as  already  stated, 
they  may  be  manifested  by  very  slight  subjective  symp- 
toms. When  carefully  observed,  these  changes  are  found 
to  precede  by  some  days,  if  not  longer,  the  onset  of  struct- 
ural disease  in  the  sympathizing  eye,  the  morbid  process 
apparently  taking  some  days  to  travel  from  one  eye  to  the 
other. 

TREATMENT. — By  far  the  most  important  measure  refers 
to  prevention.  When  once  sympathetic  inflammation  has 
begun  we  can  do  little  to  modify  its  course.  The  clear  rec- 
ognition of  this  fact  leads  us  to  advise  the  excision  of 
every  eye  which  is  at  the  same  time  useless  and  liable  to 
cause  sympathetic  mischief,  i.  e.,  of  all  eyes  which  are  blind 
from  disease  of  the  anterior  segment  of  the  globe;  and  to 
give  this  advice  most  urgently  when  the  blind  eye  is  al- 
ready tender  or  irritable,  or  is  liable  to  become  so,  when  it 
has  been  lost  by  wound,  and  when  it  is  probable  that  it 
may  contain  a  foreign  body.  Any  lost  eye  in  which  there 
are  signs  of  past  iritis,  whether  it  has  been  injured  or  not, 
is  best  removed,  especially  if  shrunken.  But  much  judg- 
ment is  needed  if  the  damaged  eye,  though  irritable  and 
likely  to  cause  mischief,  still  retains  more  or  less  sight. 
Every  attention  must  then  be  paid  to  the  exact  position  of 
the  wound,  the  evidence  as  to  its  depth,  the  condition  of 
the  lens,  the  evidence  of  hemorrhage,  and  especially  to  the 


156      DISEASES    OF     THE    CILIAKY    REGION. 

yellowish  haziness  behind  the  lens,  which  indicates  lymph 
or  pus  in  the  vitreous  (p.  151).  The  date  of  the  injury 
and  the  condition  of  the  wound,  whether  healed  by  imme- 
diate union,  or  with  scarring,  puckering  or  flattening,  are 
very  important  points.  Irritation  of  the  fellow  eye  may 
set  in  a  few  days  after  the  injury;  but  since  inflammation 
very  seldom  begins  sooner  than  two  or  three  weeks,  we 
may,  if  we  see  the  case  early,  watch  it  for  a  little  time. 
Complete  and  prolonged  rest  in  a  darkened  room  is  a  very 
important  element  in  the  prevention  of  sympathetic  irrita- 
tion and  inflammation,  and  should  always  be  insisted  on 
when  we  are  trying  to  save  an  injured  eye  (compare  p.  142). 
In  rare  cases  sympathetic  inflammation  sets  in  after  the  re- 
moval of  the  exciting  eye,  even  after  an  interval  of  several 
weeks,  a  contingency  which  emphasizes  the  importance  of 
excising  at  the  earliest  possible  moment. 

When  sympathetic  ophthalmitis  has  set  in  we  can  do  com- 
paratively little. 

A.  The  exciting  eye,  if  quite  blind  or  so  seriously  dam- 
aged as  to  be  certainly  for  practical  purposes  useless,  is  to 
be  excised  at  once,  though  the  evidence  of  benefit  from 
this  course  is  slender.     But  it  is  not  to  be  removed  if  there 
is  reason  to  hope  for  restoration  of  useful  sight  in  it ;  if 
there  be  simply  a  moderate  degree  of  subacute  irido-cyclitis 
with  or  without  traumatic  cataract,  and  with  sight  propor- 
tionate to  the  state  of  the  lens,  the  eye  is  to  be  carefully 
treated,  since  it  may  very  probably  in  the  end  be  the 
better  of  the  two  (p.  153). 

B.  Ttie  sympathizing  eye.     The  important  measures  are 
(1)  atropine,  used  very  often  as  for  acute  iritis;  (2)  abso-' 
lute  rest  and  exclusion  of  light  by  residence  in  a  dark 
room  and  with  a  black  bandage  over  the  eyes ;    (3)  re- 
peated leeching  if  the  symptoms  are  severe,  or  counter- 
irritation  by  blisters  or  by  a  seton  in  chronic  cases.     (4) 
Mercury  is  believed  by  some  to  be  beneficial.     Quinine  is 


DISEASES    OP     THE     CILIARY    REGION.       157 

sometimes  given.  (5)  No  operation  is  permissible  till  the 
disease  has  come  to  a  standstill ;  iridectomy,  whilst  there 
are  active  symptoms,  is  followed  by  closure  of  the  gap 
with  fresh  lymph.  When  there  is  total  posterior  synechia 
and  secondary  cataract,  removal  of  the  lens  and  a  large 
piece  of  iris  by  a  special  operation  will  finally  be  proper 
if  the  state  of  the  eye  in  other  respects  makes  it  worth 
while. 

The  PROGNOSIS  is,  as  will  be  gathered,  very  grave;  even 
in  the  mildest  cases,  when  seen  quite  early,  we  must  be 
very  cautious,  for  the  disease  often  slowly  progresses  for 
many  months. 

14 


158  INJURIES. 


CHAPTER   XL 

* 

INJURIES. 

INJURIES  may  be  divided  into  those  which  affect  the 
eyeball  itself  and  those  limited  to  the  surrounding  orbital 
structures.  In  each  class  a  broad  distinction  is  to  be  made 
between  contusion  and  concussion  injuries  and  wounds. 

A.  INJURIES  OF  PARTS  AROUND  THE  EYEBALL. 

(1)  Contusion  and  concussion  injuries. — Ecchymosis  of 
the  skin  of  the  eyelids  from  direct  blows  ("  black  eye  ")  is 
to  be  distinguished  from  extravasation  into  the  orbital  cel- 
lular tissue  following  fracture  of  the  walls  of  the  orbit. 
In  ordinary  "black  eye"  the  ecchymosis  is  superficial,  and, 
if  it  affect  either  the  palpebral  or  ocular  conjunctiva,  does 
not  pass  far  back.  The  ecchymosis  following  orbital  fract- 
ure is  deep-seated,  often  entirely  beneath,  rather  than  in, 
the  skin  and  conjunctiva,  diminishes  in  density  towards 
the  front  and  borders  of  the  lids,  and  when  considerable 
may  cause  proptosis.  The  '.wo  forms  may  be  combined 
when  fracture  is  caused  by  direct  violence  to  the  orbit. 
Cold  bathing,  or  an  evaporating  lotion  will  hasten  the  ab- 
sorption of  the  blood  in  ordinary  "  black  eye." 

Fracture  of  the  inner  wall  of  the  orbit  into  the  nose, 
the  sinuses  opening  into  it,  or  the  nasal  duct,  is  often 
followed  by  emphysema,  of  the  orbital  cellular  tissue.  This 
can  occur  only  when  the  mucous  membrane  is  torn.  The 
emphysema  comes  on  quickly  from  "blowing  the  nose," 
and  is  shown  by  a  soft,  whitish,  doughy  swelling  of  the 


INJURIES.  159 

lids,  which  crepitates  finely  under  the  finger;  the  globe  is 
more  or  less  protruded,  and  its  movements  limited.  The 
emphysema  disappears  in  a  few  days  if  the  lids  be  kept 
rather  firmly  bandaged.  These  fractures  are  usually  caused 
by  blows  over  the  inner  angle  of  the  orbit,  but  occasionally 
by  blows  over  its  outer  rim. 

Partial  ptosis  is  tui  occasional  result  of  blows  upon  the 
upper  lid.  It  is  generally  accompanied  by  paralysis  of 
accommodation  and  partial  dilatation  of  the  pupil,  and  it 
seldom  lasts  more  than  a  few  weeks. 

But  the  most  serious,  though  rare,  consequences  which 
may  follow  blows  about  the  orbit,  either  quickly  or  after 
an  interval,  are  acute  and  chronic  orbital  abscess  and  cel- 
lulitis.  Diffused  acute  inflammation  of  the  cellular  tissue 
is  difficult  to  distinguish  from  acute  orbital  abscess,  since 
in  both  there  are  the  signs  of  deep  inflammation,  with  dis- 
placement of  the  eye  and  limitation  of  its  movements, 
chemosis  of  the  conjunctiva,  and  brawny  swelling  and  red- 
ness of  the  lids.  An  abscess  will  soon  point  towards  some 
part  of  the  eyelids,  but  even  in  cellulitis  the  swelling  may 
be  greater  at  some  one  part,  and  a  feeling  deceptively  like 
fluctuation  may  be  present. 

Orbital  abscess  may  be  very  chronic,  and  simulate  a 
solid  tumor  until  the  pus  nears  the  surface;  even  then  we 
may  not  be  able  to  distinguish  it  from  a  cystic  tumor,  until 
an  exploratory  incision  sets  the  question  at  rest  (compare 
p.  89).  Abscess  of  the  orbit,  whether  acute  or  chronic,  is 
very  often  the  result  of  injury  which  has  given  rise  to 
periostitis,  and  a  large  surface  of  bone  is  often  laid  bare. 

In  acute  cases  an  exploratory  incision  is  to  be  made  with 
a  narrow  straight  knife,  generally  through  the  skin,  or  if 
practicable  through  the  conjunctiva,  as  soon  as  fluctuation 
is  detected.  As  the  pus  is  often  curdy,  it  is  best  not  to 
use  a  grooved  needle.  Chronic  cases  of  doubtful  nature 
may  be  watched  for  a  time.  It  may  be  necessary  to  go 


160  INJURIES. 

deeply  into  the  orbit  cither  with  the  knife,  probe,  or  dress- 
ing forceps,  before  matter  is  reached.  A  drainage-tube 
should  be  inserted  if  the  abscess  be  deep.  The  proptosis 
does  not  always  disappear  when  an  orbital  abscess  is 
opened,  for  in  addition  to  hemorrhage  caused  by  the 
operation  there  may  be  much  thickening  of  the  tissues. 
Sight  may  be  injured  or  lost  by  stretching  of,  or  pressure  on, 
the  optic  nerve,  and  the  cornea  may  become  anaesthetic  and 
ulcerate  from  damage  to  the  ciliary  nerve  behind  the  globe. 

(2)  Wounds. — Wounds  of  the  eyelids  need  no  special 
treatment,  beyond  very  careful  apposition  of  sutures,  some- 
times with  a  small  harelip  pin,  so  as  to  secure  primary  and 
accurate  union.  Lacerated  wounds  of  the  ocular  con- 
junctiva need  a  few  fine  sutures  if  extensive,  and  they  sel- 
dom lead  to  any  deformity. 

Occasionally  one  of  the  recti  tendons  is  divided  or  torn 
through,  but  it  can  seldom  be  kept  in  place  by  sutures. 

Penetrating  wounds  through  the  lids  or  conjunctiva, 
which  pass  deeply  into  the  orbit,  may  be  much  more  serious 
than  they  appear  at  first  sight,  since  the  wounding  body 
may  have  caused  fracture  of  the  orbit,  and  damage  to  the 
brain-membranes,  or  a  piece  of  the  wounding  instrument 
may  have  been  broken  off  and  lie  imbedded  in  the  roomy 
cavity  of  the  orbit  without  at  first  exciting  disturbance  or 
causing  displacement  of  the  eye.  Some  most  extraordi- 
nary cases  are  on  record  in  which  very  large  fragments  of 
iron  or  other  substances  have  lain  in  the  orbit  for  a  long 
time  undetected.  The  optic  nerve  is  occasionally  torn 
across  without  damage  to  the  globe.  Every  wound  of  the 
eyelids  or  conjunctiva  should  therefore  be  carefully  ex- 
plored with  the  probe,  and  whenever  possible  the  instru- 
ment which  caused  the  wound  should  be  examined.  When 
a  foreign  body  is  suspected,  or  knoAvn,  to  be  firmly  em- 
bedded, and  is  not  removable  through  the  original  wound, 
it  is  generally  better  to  divide  the  outer  canthus,  and  pro- 


INJURIES.  161 

long  the  incision  into  the  conjunctiva,  than  to  divide  the 
lid  itself.  In  other  cases  an  incision  through  the  skin,  over 
the  margin  of  the  orbit,  at  the  situation  of  the  foreign 
body,  will  be  preferable.  Single  shot  corns,  imbedded  and 
causing  no  symptoms,  should  not  be  interfered  with  unless 
they  can  be  easily  reached. 

Wounds  of  the  orbit,  by  gunshot  or  other  explosions, 
when  extensive  and  caused  by  numerous  shots  or  frag- 
ments of  sand,  gravel,  etc.,  driven  into  the  tissues,  are 
serious,  because  the  eyeball  itself  is  often  injured ;  tetanus 
may  also  occur. 

B.  INJURIES  OF  THE  EYEBALL. 

(1)  Contusion  and  concussion  injuries. — Rupture  of  the 
eyeball  is  commonly  the  result  of  severe  direct  blows.  The 
rent  is  nearly  always  in  the  sclerotic,  either  a  little  behind, 
or  close  to  the  corneal  margin,  with  which  it  is  concentric; 
the  cornea  itself  is  but  seldom  rent  by  a  blow.  The  rupt- 
ure is  usually  large,  involves  all  the  tunics,  and  is  followed 
by  hemorrhage  between  the  retina  and  choroid,  and  into 
the  vitreous  and  anterior  chambers,  and  often  by  escape 
of  the  lens  and  of  some  of  the  vitreous ;  sight  is  usually 
reduced  to  perception  of  light  or  of  large  objects.  The 
conjunctiva,  however,  often  escapes  untorn,  and  in  such  a 
case  if  the  lens  pass  through  the  rent  in  the  sclerotic,  it 
will  be  held  down  by  the  conjunctiva,  and  form  a  promi- 
nent, rounded,  translucent  swelling  over  the.  rupture.  The 
diagnosis  of  rupture  is  generally  easy,  even  if  the  rent  be 
more  or  less  concealed.  Shrinking  of  the  eyeball  is  a  com- 
mon result,  but  occasionally  some  vision  is  restored.  Im- 
mediate excision  is  often  best,  but  when  there  is  room  for 
hope,  we  should  always  wait  until  the  absorption  of  the 
blood  in  the  anterior  chamber  allows  the  deeper  parts  to 
be  seen.  The  treatment  will  be  the  same  as  for  wounds  of 
the  eye  (p.  170). 

14* 


162 


INJURIES. 


It  may  here  be  mentioned  that  copious  hemorrhage,  ac- 
companied by  severe  pain,  sometimes  occurs  between  the 
choroid  and  sclerotic  as  the  result  of  sudden  diminution 
of  tension,  cither  by  an  operation,  such  as  extraction  of 
cataract  or  iridectomy,  or  by  a  glancing  wound  of  the  cor- 
nea. Eyes  in  which  this  occurs  are  for  the  most  part  al- 
ready unsound,  and  often  glaucomatous. 

Blows  often  cause  internal  damage  without  rupture  of  the 
hard  coats  of  the  eye.  The  iris  may  be  torn  from  its  ciliary 
attachment  (coredialysi^t,  so  that  two  pupils  are  formed 
(Fig.  53)  or  the  lens  Lo  loosened  or  displaced  (p.  187) 

FIG.  53. 


Separation  of  iris  following  a  blow  (after  Lawson). 

by  partial  rupture  of  its  suspensory  ligament,  so  that  the 
iris  having  lost  its  support  will  shake  about  with  every 
movement  (tremulous  iris).  Such  lesions  are  likely  to  be 
attended  with  bleeding  into  the  anterior  chamber  and 
into  the  vitreous,  arid  the  real  condition  may  thus  be  ob- 
scured for  a  time.  The  lens  often  becomes  opaque  after- 
wards. Detachment  of  the  retina  is  often  found  after 
severe  blows,  which  have  caused  hemorrhage  into  the  vi- 
treous. Blows  on  the  front  of  the  eye  may  cause  rupture 
of  the  choroid,  or  hemorrhage  from  choroidal  or  retinal 
vessels.  These  changes  are  found  at  the  central  part  of 
the  fundus,  often  almost  exactly  at  the  yellow  spot,  thus 
causing  much  damage  to  sight.  The  rents  in  the  choroid 
appear  after  the  blood  has  cleared  up,  as  lines  or  narrow 


INJURIES.  l(lo 

bands  of  atrophy  bordered  by  pigment,  and  often  slightly 
curved  towards  the  disk  (Fig.  GGj.  Hemorrhages  from  the 
choroidal  vessels  without  rupture  of  the  choroid,  usually 
leave  some  pigment  behind  after  absorption.  Paralysis  of 
the  iris  and  ciliary  muscle,  with  partial  aud  often  irregular 
dilatation  of  the  pupil,  is  sometimes  the  sole  result  of  a 
blow  on  the  eye.  The  defect  of  sight  can  be  remedied  by  a 
convex  lens.  When  uncomplicated  these  symptoms  are  sel- 
dom permanent.  (See  also  Traumatic  Iritis,  pp.  140,  141.) 
Great  defect  of  sight  following  a  blow,  and  neither  reme- 
died by  glasses  nor  accounted  for  by  blood  in  the  anterior 
chamber,  will  generally  mean  copious  hemorrhage  into  the 
vitreous,  with  or  without  the  other  changes  just  mentioned 
in  the  retina  and  choroid.  The  red  blood  may  sometimes 
be  seen  by  focal  light,  but  often  its  pi'esence  can  only  be 
inferred  from  the  opaque  state  of  the  vitreous.  Probably 
in  most  of  these  cases  the  blood  comes  from  the  large  veins 
of  the  ciliary  body,  but  sometimes  from  the  choroid  or 
vessels  of  the  retina.  There  may  be  no  external  ecchymo- 
sis.  The  tension  of  the  globe  is  to  be  noted ;  it  is  not  often 
increased  unless  inflammation  has  set  in  or  the  eye  was  pre- 
viously glaucomatous,  and  in  some  cases  it  is  below  par. 
The  prognosis  should  be  very  guarded  whenever  there  is 
reason  to  think,  from  the  opaque  state  of  the  vitreous,  that 
much  bleeding  has  taken  place,  or  when  the  iris  is  tremu- 
lous or  partly  detached,  or  if  any  rupture  of  the  choroid 
can  be  made  out.  Blood  in  the  anterior  chamber  is  gen- 
erally absorbed  within  a  few  days,  but  in  the  vitreous  ab- 
sorption is  more  tardy  and  less  complete,  permanent  opaci- 
ties often  being  left.  The  use  of  atropine.  the  frequent 
application  of  iced  water,  or  of  an  evaporating  lotion,  to 
the  lids,  and  occasional  leeching  if  there  are  inflammatory 
symptoms,  will  do  all  that  is  possible  in  the  early  periods. 
If  the  lens  be  loosened  it  is  likely  in  time  to  become  opaque, 
and  it  may  at  any  time  act  as  an  irritating  foreign  body, 


164  INJURIES. 

and  set  up  a  glaucomatous  inflammation,  or  cause  sympa- 
thetic symptoms  iu  the  other  eye  (p.  187).  Now  and  then 
optic  neuritis  occurs  in  the  injured  eye  as  the  immediate 
effect  of  the  blow.  Hemorrhage  behind  the  choroid  is  be- 
lieved to  account  for  certain  well-known  cases  in  which, 
after  a  blow,  there  is  defect  of  sight  without  visible  change, 
or  with  localized  and  temporary  haze  of  retina  ("  commotio 
retina").  Temporary  myopia  or  astigmatism  may  also  fol- 
low a  blow  on  the  eye;  such  changes  of  refraction  depend 
on  altered  curvature  of  the  lens,  and  are  sometimes  entirely 
removed  by  paralyzing  the  ciliary  muscle  with  atropine. 

(2)  Wounds. — A.  Surface  scratches  (abrasions')  of  the 
cornea  cause  much  pain,  watering,  and  photophobia  with 
ciliary  congestion.  They  are  frequently  due  to  a  scratch 
by  the  finger-nail  of  a  baby  in  nursing.  The  abraded  sur- 
face is  often  very  small  and  shows  no  opacity  ;  it  is  detected 
by  watching  the  reflection  of  a  window  from  the  cornea  (p. 
CO),  whilst  the  patient  slowly  moves  his  eye.  Now  and  then 
the  irritability  persists,  or  recurs  after  an  interval. 

Minute  fragments  of  metal  or  stone  flying  from  tools, 
etc.,  often  partly  imbed  themselves  in  the  cornea  (foreign 
body  on  the  cornea),  and  give  rise  to  varying  degrees  of  irri- 
tability and  pain.  If  not  removed,  such  a  fragment  is  soon 
surrounded  by  a  hazy  zone  of  infiltration.  Foreign  bodies 
are  easily  seen  unless  either  very  small  or  covered  up  by 
mucus  or  epithelium.  In  a  doubtful  case,  examination  by 
focal  light  (p.  60)  will  show  the  dark  speck,  even  when  it 
is  invisible  by  daylight. 

The  pupil  is  often  smaller  than  its  fellow,  and  the  color 
of  the  iris  altered,  in  cases  of  abrasion  and  of  foreign  body 
on  the  cornea,  indicating  congestion  of  the  iris  (p.  40). 
Actual  iritis  sometimes  occurs,  but  not  unless  the  corneal 
wound  becomes  inflamed  and  infiltrated. 

TREATMENT. — (For  removal  of  foreign  bodies,  see  Opera- 
tions.) After  surface  injuries  use  a  drop  of  castor  oil  to 


INJURIES.  165 

lubricate  the  cornea,  and  apply  a  pad  of  wadding  and  a 
single  length  of  bandage  tied  behind  the  head.  Atropine 
is  required  if  there  is  much  irritation  or  threatened  iritis. 
If  iritis  with  hypopyon  arise,  the  case  will  become  one  of 
hypopyon  ulcer  (pp.  117  and  122). 

Foreign  bodies  often  adhere  to  the  inner  surface  of  the 
upper  lid,  and  the  lid  must  therefore  be  everted,  and  exam- 
ined whenever  a  patient  with  a  corneal  abrasion  states  that 
he  has  "something  in  his  eye." 

Large  bodies  sometimes  pass  far  back  into  the  upper  or 
lower  conjunctiva!  sulcus  and  lie  hidden  for  weeks  or 
months,  causing  only  local  inflammation  and  some  thicken- 
ing of  the  conjunctiva.  Search  must  be  made,  if  needful, 
wyith  a  wire  loop  or  probe  whenever  the  suspicion  arises 
(compare  p.  160). 

B.  Burns,  scalds,  and  injuries  by  caustics,  etc. — The  con- 
junctiva and  cornea  are  often  damaged  by  splashes  of 
molten  lead,  or  by  strong  alkalies  or  acids,  of  which  lime, 
either  quick  or  freshly  slaked,  is  one  of  the  commonest. 
The  eyeball  is  not  often  scalded,  the  lids  closing  quickly 
enough  to  prevent  entrance  of  the  steam  or  hot  water.  In 
none  of  these  cases  is  the  full  eifect  apparent  for  some  days, 
and  a  cautious  opinion  should,  therefore,  always  be  given 
when  the  case  is  seen  very  early. 

The  effects  of  such  accidents  aro  manifested  by  (1)  in- 
flammation, with  or  without  ulceration,  of  the  cornea;  (2) 
scarring  and  shortening  of  the  conjunctiva,  and  in  bad 
cases,  adhesion  of  its  palpebral  and  ocular  surfaces — 
symblepharon ;  (3)  suppurative  keratitis  and  hypopyon  in 
severe  cases. 

The  most  superficial  burns  whiten  and  dry  the  surface, 
and  in  a  few  hours  the  epithelium  is  shed.  This  is  shown 
on  the  cornea  by  a  sharply  outlined,  slightly  depressed 
area,  the  floor  of  which  is  clear  if  the  damage  be  quite 
superficial  and  recent,  but  more  or  less  opalescent,  or  even 


16(3  INJUKIES. 

yellowish,  if  the  case  be  a  few  days  old  and  the  burn  be 
deep  enough  to  have  caused  destruction  or  inflammation 
of  the  true  corneal  tissue.  When  there  is  much  opacity  it 
does  not  completely  clear,  and  considerable  flattening  of 
the  cornea  and  neighboring  sclerotic  often  occurs  at  the 
seat  of  deep  and  extensive  burns.  The  conj  uncti val  whiten- 
ing is  followed  by  mere  desquamation  and  vascular  reaction, 
or  by  ulceration  and  scarring,  according  to  the  depth  of 
the  damage. 

TREATMENT. — In  recent  cases,  seen  before  reaction  has 
begun,  a  drop  of  castor  oil  once  or  twice  a  day,  a  few 
leeches  to  the  temple,  and  the  use  of  a  cold  evaporating 
lotion,  or  of  iced  water,  will  sometimes  prevent  inflamma- 
tion. If  seen  immediately  after  the  accident,  the  coujunc- 
tival  sac  is  to  be  carefully  searched  for  fragments  of 
whatever  solid  has  caused  the  mischief,  or  washed  with 
very  W7eak  acid  or  alkaline  solution  if  a  caustic  of  the 
opposite  character  have  done  the  damage.  If  inflammatory 
reaction  is  already  present  when  the  case  comes  to  notice, 
treatment  by  compress,  atropine,  and  hot  fomentations,  as 
recommended  for  hypopyon  ulcers  (p.  122),  is  most  suitable. 
There  is  often  much  pain  and  chemosis.  Buttons  of  gran- 
ulation forming  on  the  floor  of  a  healing  burn  of  conjuctiva 
should  be  snipped  off*. 

c.  Penetrating  wounds  and  gunshot  injuries. — When  a 
patient  says  that  his  eye  is  wounded,  the  first  point  is  to 
examine  the  seat,  extent,  and  character  of  the  wound, 
ascertain  the  interval  since  the  injury,  and  test  the  sight 
of  the  eye ;  the  next  step  is  to  make  out  all  we  can  about 
the  wounding  body,  and  especially  whether  or  not  any 
fragment  has  been  left  within  the  eyeball. 

Very  large  foreign  bodies,  such  as  pieces  of  glass,  some- 
times lie  for  a  long  time  in  the  eye  without  causing  much 
trouble,  the  large  wound  having  given  exit  to  the  contents 


INJURIES.  1G7 

of  the  globe  and  been  followed  by  rapid  shrinking  Avithout 
inflammation. 

TREATMENT. — Penetrating  wounds  are  least  serious  when 
they  implicate  the  cornea  alone,  or  the  sclerotic  alone 
behind  the  ciliary  region,  i.  e.,  when  situated  at  least  one- 
fourth  of  an  inch  behind  the  cornea.  Penetrating  wounds 
of  the  cornea,  without  injury  to  the  iris  or  lens,  and  with- 
out any  prolapse  of  iris,  are  rare  ;  they  generally  do  very 
well,  and  if  the  case  be  not  seen  until  one  or  two  days  after 
the  injury,  the  wound  will  often  have  healed  firmly  enough 
to  retain  the  aqueous,  and  it  may  be  difficult  to  decide 
whether  the  whole  thickness  of  the  cornea  has  been  pene- 
trated or  not.  Wounds  of  the  sclerotic  seldom  unite  with- 
out the  interposition  of  a  layer  of  lymph ;  if  seen  early 
they  should,  when  clean  and  uncomplicated  by  evidence  of 
internal  injury,  be  treated  by  the  insertion  of  one  or  two 
fine  sutures,  followed  by  the  use  of  ice  (p.  143). 

But  penetrating  wounds  usually  are  very  serious  to  the 
injured  eye;  the  iris  is  frequently  lacerated  and  included 
in  the  track  of  the  wound;  the  lens  is  punctured  and 
becomes  swollen  and  opaque  from  absorption  of  the  aqueous 
tumor  (traumatic  cataract,  p.  180),  and  liable  in  its  swollen 
state  to  press  on  the  ciliary  processes  and  cause  grave 
symptoms ;  extensive  bleeding  perhaps  takes  place  into  the 
vitreous  ;  a  few  days  later,  plastic  or  purulent  cyclitis  may 
destroy  the  eye.  The  fellow  eye  is,  of  course,  often  in 
danger  of  sympathetic  inflammation  (p.  151).  Every  case 
has  therefore  to  be  judged  from  two  points  of  view,  the 
damage  to  the  injured  eye  and  the  risk  to  the  sound  one; 
and  the  question  of  whether  to  sacrifice  or  attempt  to  save 
the  former  is  sometimes  very  difficult  to  decide. 

(I.)  In  the  two  following  cases  the  eye  should  be  excised 
at  once.  (1)  If  the  wound,  lying  wholly  or  partly  in  the 
"dangerous  region"  (p.  152),  be  so  large  and  so  compli- 
cated with  injury  to  deeper  parts  that  no  hope  of  useful 


108  INJURIES. 

sight  remains.  (2)  If,  even  though  the  wound  be  small,  it 
lie  in  the  dangerous  region,  and  have  already  set  up  irido- 
cyclitis  (p.  151). 

(II.)  There  is  a  large  class  of  cases  in  which  the  wound, 
though  in  the  ciliary  region,  or  involving  the  lens  and  iris 
through  the  cornea,  is  not  of  itself  fatal  to  sight,  and  has 
not  as  yet  led  to  inflammation  or  to  skrinking  of  the  eye. 

The  first  question  then  is  whether  the  eye  contains  a 
foreign  body,  and  if  so  whether  or  not  it  is  steel  or  iron, 
and  therefore  possibly  removable  by  a  magnet ;  the  second 
question  is  whether  the  lens  is  wounded.  A  foreign  body, 
if  lying  on  or  imbedded  in  the  iris,  the  lens  being  intact, 
should  be  removed,  usually  with  the  portion  of  iris  to  which 
it  is  attached ;  if  loose  in  the  anterior  chamber,  it  may  be 
difficult  to  remove.  If  it  can  be  seen  in  the  lens,  and  the 
condition  of  the  eye  be  otherwise  favorable,  a  scoop  ex- 
traction may  be  done  in  the  hope  of  removing  the  fragment 
with  the  lens ;  or  the  lens  may  be  allowed,  or  by  a  needle 
operation  (p.  182)  induced,  to  undergo  partial  absorption, 
so  that  in  shrinking  it  may  enclose  the  foreign  body  more 
firmly,  and  bring  this  away,  when  itself  subsequently  ex- 
tracted. If  it  is  certain  that  the  foreign  body  has  passed 
into  the  vitreous,  whether  through  the  lens  or  not,  and 
whether  by  gunshot  or  not,  it  is  seldom  possible  to  save  the 
eye ;  the  body  can  of  course  seldom  be  seen,  but  a  track  of 
opacity  through  the  lens  with  extensive  hemorrhage  into 
the  vitreous,  or  even  the  latter  alone,  with  conclusive  history 
that  the  wound  was  made  by  a  fragment  or  a  shot,  and  not 
by  an  instrument  or  large  body,  is  generally  enough  to 
settle  the  point  in  favor  of  excision.  These  rules  now  need 
modification  when  the  foreign  body  is  of  iron  or  steel,  since 
it  is  possible  in  some  cases,  by  means  of  a  strong  electro- 
magnet, to  remove  such  fragments,  even  when  lying  in  the 
vitreous.  This  may  be  done  either  through  the  wound  of 
entrance,  more  or  less  enlarged,  or  through  a  fresh  wound 


INJURIES.  169 

made  where  the  body  is  seen  or  believed  to  lie.  The  method 
is  at  present  new,  and  many  forms  of  magnet  have  been 
used,  the  most  successful,  however,  usually  being  those  in 
which  a  small  spatula  instrument,  powerfully  magnetized 
by  being  attached  to  the  core  of  an  electro-magnetic  coil, 
is  introduced  into  the  eye  in  search  of  the  body.  The 
spatula  in  an  instrument  which  I  have  used  will,  when  the 
circuit  is  complete,  lift  between  six  and  eight  ounces. 
Though  a  considerable  number  of  eyes  have  now  been  saved 
with  more  or  less  useful  sight,  by  the  use  of  the  magnet,  it 
must  be  remembered  that  the  extraction  of  the  foreign  body 
does  not  insure  the  safety  of  the  eye ;  that  it  may  inflame 
or  shrink,  and  remain  as  potent  a  source  of  sympathetic 
disease  as  before,  especially  so  if  iritis  or  threatened  pan- 
ophthalmitis  were  present  at  the  time  of  operation.1 

(III.)  There  remain  cases  of  less  severe  character,  and 
in  which  no  foreign  body  remains  in  the  eye:  (1)  the  wound 
is  in  the  dangerous  region  and  complicated  with  traumatic 
cataract ;  (2)  in  the  dangerous  region  without  traumatic 
cataract ;  (3)  there  is  traumatic  cataract,  but  the  wound  is 
corneal,  and,  therefore,  out  of  the  dangerous  zone.  In  the 
first,  and  still  more  in  the  second  of  these,  there  will  often 
be  much  difficulty  in  deciding  what  to  do,  it  being  presumed 
that  the  wounded  eye  shows  no  iritis  or  other  signs  of  severe 
inflammation.  Some  of  the  most  difficult  cases  are  those 
in  group  (2)  of  wounds  by  sharp  instruments  close  to  the 
corneal  border,  with  considerable  adhesion  of  the  iris,  or 
in  which  there  is  evidence  that  the  track  lies  between  the 
lens  and  the  ciliary  processes,  the  lens  not  being  wounded, 
and  useful  sight  remaining.  If  the  patient  be  seen  within 
two  or  three  weeks  of  the  injury,  and  the  sound  eye  shows 

1  Mr.  McHardy,  who  was  one  of  the  first  to  bring  the  subject 
forward,  has  just  given  a  detailed  account  of  some  of  the  best 
forms  of  electro-magnet  in  vol.  i.  of  the  Transactions  of  the  Oph- 
thalmological  Society  (1881). 

15 


170  INJURIES. 

no  irritation,  we  may  safely  watch  the  case  for  a  few  days. 
If  decided  sympathetic  irritation  (see  p.  153)  be  present, 
and  do  not  yield  after  a  few  days'  treatment,  excision  is 
advisable,  even  though  the  lens  of  the  wounded  eye  be  un- 
injured. I  think  that  if  we  made  a  rule  of  excising  every 
eye  with  wound  in  the  ciliary  region  and  traumatic  cata- 
ract (group  1),  whether  or  not  it  were  causing  sympathetic 
symptoms  or  were  itself  especially  irritable,  we  should  not 
be  far  wrong,  for  the  prospect  of  regaining  useful  vision  in 
the  eye  under  such  circumstances  is  often  slight.  In  the 
third  group,  excision  is  justifiable  only  in  the  rare  cases 
where  severe  iritis  and  threatened  panophthalmitis  come 
on.  The  patient  in  all  open  cases  must  be  warned,  and 
must  be  seen  every  few  days  for  many  weeks. 

When  sympathetic  ophthalmitis  (p.  153)  has  set  in  before 
the  patient  asks  advice,  the  rule  as  to  excision  of  the  ex- 
citing eye  is  different  (p.  157). 

The  treatment  of  wounded  eyes  which  are  not  excised  is 
the  same  as  for  traumatic  iritis  and  cataract,  viz.,  atropine, 
rest,  and  local  depletion  (see  pp.  141  and  180).  If  seen 
before  inflammation  (iritis)  has  begun,  ice  is  to  be  used 
(p.  143).  When  the  iris  has  prolapsed  into  the  wound  the 
protrusion  should  usually  be  cut  off,  and  the  cut  ends,  if 
possible,  returned  into  the  anterior  chamber  (see  Iridec- 
tomy) ;  if  seen  a  few  hours  after  the  wound,  the  prolapse 
can  sometimes  be  returned,  or  will  retract  under  the  use  of 
eserine. 

It  is  sometimes  important  to  determine  whether  an  ex- 
cised eye  contains  a  foreign  body.  If  nothing  can  be  found 
in  the  blood  or  lymph,  etc.,  by  feeling  with  a  probe,  it  is 
best  to  crush  the  soft  parts,  little  by  little,  between  finger 
and  thumb,  when  the  smallest  particle  will  be  felt.  If  a 
shot  has  entered  and  left  the  eye,  the  counter-opening 
may,  if  recent,  be  found  from  the  inside,  although  no  ir- 
regularity be  noticeable  outside  the  eyeball. 


CATARACT.  171 


CHAPTER    XII. 

CATARACT. 

CATARACT  means  opacity  of  the  crystalline  lens,  and  is 
due  to  changes  in  the  structure  and  composition  of  the  lens- 
fibres.  The  capsule  is  often  thickened,  but  otherwise  not 
materially  altered.  These  changes  seldom  occur  through- 
out the  whole  lens  at  once,  but  begin  first  in  a  certain  re- 
gion, e.  g.,  the  centre  (nucleus)  or  the  superficial  layers 
(cortex),  whilst  in  some  of  the  forms  of  partial  cataract  the 
disease  remains  permanently  confined  to  some  well-circum- 
scribed part. 

Senile  changes  in  the  lens. — With  advancing  age  the  lens, 
which  is  from  birth  firmest  at  the  centre,  becomes  harder 
and  flatter,  and  acquires  a  yellow  color;  its  refractive 
power  changes,  its  surface  reflects  more  light,  and  its  sub- 
stance becomes  somewhat  fluorescent.  The  result  of  all 
these  changes  is  that  at  an  advanced  age  the  lens  is  more 
easily  visible  than  in  early  life,  the  pupil  becoming  grayish 
instead  of  quite  black.  This  grayness  of  the  pupil  may 
easily  be  mistaken  for  cataract,  but  ophthalmoscopic  ex- 
amination shows  that  the  lens  is  quite  transparent,  and  the 
fundus  seen  without  any  blurring. 

The  consistence  of  a  cataract  depends  more  on  the  pa- 
tient's age  than  on  the  position  or  character  of  the  opacity. 
Below  about  thirty-five  all  cataracts  are  "soft,"  and  the 
wide  physical  differences  between  cataracts  depend  less  on 
variations  in  the  cause,  than  on  the  degree  of  natural  hard- 
ness the  lens  possesses  when  the  opacity  sets  in. 


172  CATARACT. 


FORMS  OF  GENERAL  CATARACT. 

(1)  Nuclear  cataract. — The  opacity  begins  in,  and  re- 
mains more  dense  at,  the  nucleus  of  the  lens,  thinning  off 
gradually  in  all  directions  towards  the  cortex  (Fig.  56)  ; 
the  nucleus  is  not  really  opaque,  but  densely  hazy  like 
thick  fog.     The  patients  are  generally  old  people,  in  whom 
the  nucleus   is    naturally  very   firm   and  yellow;   hence 
nuclear  cataract  is  also  usually  senile  and  hard,  to  v/hich 
we  may  add  that  it  is  often  amber-colored  or  light  brownish, 
like  "  peasoup  "  fog. 

(2)  Cortical  cataract. — The  change  begins  in  the  super- 
ficial parts,  and  generally  in  the  form  of  sharply  defined 
lines  or  streaks,  or  triangular  patches,  which  point  towards 
the  axis  of  the  lens,  and  whose  shape  is  dependent  on  the 
arrangement  of  the  lens  fibres  (Fig.  57).     They  usually 
begin  at  the  edge  (equator)  of  the  lens  where  they  are 
hidden  by  the  iris,  but  when  large  enough  they  encroach 
on   the   pupil  as  whitish   streaks  or  triangular  patches. 
They  affect  both  the  anterior  and  posterior  layers  of  the 
lens,  and  the  intervening  parts  may  be  quite  clear.    Sooner 
or  later  the  nucleus  also  becomes  hazy  (mixed  cataract), 
and  the  whole  lens  eventually  gets  opaque. 

Some  cases  of  the  large  class  known  as  "  senile  "  or  "hard  " 
cataract  are  nuclear  from  beginning  to  end,  i.  e.,  formed  by 
gradual  extension  of  diffused  opacity  from  the  centre  to  the 
surface ;  more  commonly  they  are  of  the  mixed  variety. 

A  few  cataracts  beginning  at  the  nucleus,  and  many  be- 
ginning at  the  cortex,  are  not  senile  in  the  sense  of  accom- 
panying old  age,  and  are,  therefore,  not  hard.  Some  such 
are  caused  by  diabetes,  but  in  many  it  is  impossible  to  say, 
except  by  a  general  reference  to  bad  health  or  premature 
senility,  why  the  lens  should  have  become  diseased.  Many 
such  are  known  as  "soft"  cataracts  when  complete.  They 
generally  form  quickly  in  a  few  months.  A  few  are  con- 


CATARACT.  173 

genital.  Whether  nuclear  or  cortical,  they  are  whiter  and 
more  uniform  looking  than  the  slower  cataracts  of  old  age, 
and  the  cortex  often  has  a  sheen  like  satin,  or  looks  flaky, 
like  spermaceti. 

In  some  cortical  cataracts  we  find  only  a  great  number 
of  very  small  dots  or  short  streaks  (dotted  cortical  cataract). 
Occasionally  a  single  large  wedge-shaped  opacity  will  form 
at  some  part  of  the  cortex  and  remain  stationary  and  soli- 
tary for  many  years.  Sometimes  in  suspected  cataract, 
though  no  opaque  striae  are  visible  by  focal  illumination, 
one  or  more  dark  streaks  are  seen  with  the  mirror  which 
alter  as  it  is  differently  inclined,  and  have  much  the  same 
optical  effect  as  cracks  in  glass.  These  "flaws"  should 
always  be  looked  on  as  the  beginning  of  cataract. 

PARTIAL  CATARACT. 

Three  forms  need  special  notice. 

(1)  Lamellar  (zonular)  cataract  is  a  peculiar  and  well- 
marked  form  in  which  the  superficial  laminse  and  the  nu- 
cleus of  the  lens  are  clear,  a  layer  or  shell  of  opacity  being 
present  between  them  (Fig.  59).     It  is  uncertain  whether 
the  opacity  is  present  at  birth  or  formed  a  few  months  later; 
it  certainly  never  forms  in  after-life.     The  great  majority 
of  its  subjects  suffer  from  infantile  convulsions.     The  size 
of  the  opaque  lamella  or  shell,  and,  therefore,  its  depth 
from  the  surface  of  the  lens,  is  subject  to  much  variation, 
and  it  may  be  much  smaller  than  is  shown  in  the  figure. 
The  opacity  is  often  stationary  for  years,  perhaps  for  life ; 
and  though  it  is  generally  believed  that  the  cataract,  if 
allowed   to  take  its  course,  eventually  becomes  general, 
cases  in  which  this  can  be  proved  are  rare. 

(2)  Pyramidal  cataract. — A  small,  sharply  defined  spot 
of  chalky-white    opacity  is  present  in  the  middle  of  the 
pupil  (at  the  anterior  pole  of  the  lens),  looking  as  if  it  lay 
upon  the  capsule.     When  viewed  sideways,  it  seems  to  be 

15* 


174 


CATARACT. 


superficially  imbedded   in  the  lens,  and   also   sometimes 
stands  forwards  as  a  little  nipple  or  pyramid  (Fig.  54). 


FIG.  54. 


Pyramidal  cataract  seen  from  the  front  and  in  section. 

It  consists  of  the  degenerated  products  of  a  localized  in- 
flammation just  beneath  the  lens-capsule,  with  the  addition 
of  organized  lymph  derived  from  the  iris  and  deposited  on 
the  front  of  the  capsule,  the  capsule  itself  being  puckered 

FIG.  55. 


Magnified  section  of  a  pyramidal  cataract.  The  fine  parallel  shading 
shows  the  thickness  of  the  opacity,  the  double  (black  and  white)  outline 
is  the  capsule;  on  each  side  are  the  cortical  lens  fibres,  many  being 
broken  up  into  globules  beneath  the  opacity.  Lying  upon  the  puckered 
capsule  over  the  opacity  is  a  little  fibrous  tissue,  the  result  of  iritis. 

and  folded  (Fig.  55).     It  is  always  stationary  and  never 
becomes  general. 

Pyramidal  cataract  is  the  result  of  central  perforating 
ulceration  of  the  cornea  in  early  life,  and  of  this  ophthal- 
mia neonatorum  is  nearly  always  the  cause.  It  is  gener- 
ally associated  with  central  opacity  of  the  cornea.  The 
contact  between  the  exposed  part  of  the  lens-capsule  and 
the  inflamed  cornea,  which  occurs  when  the  aqueous  has 
escaped  through  the  hole  in  the  ulcer,  appears  to  set  up  the 
localized  subcapsular  inflammation.  It  is  probable  that 
the  same  change  may  occur  in  ophthalmia  of  infants  with- 


CATARACT.  175 

out  perforation  of  the  cornea,  and  iritis  in  very  early  life 
may  also  cause  similar  opacities. 

The  term  anterior  polar  cataract  is  applied  both  to  the 
pyramidal  form  and  to  some  less  common  varieties  which 
begin  in  the  same  part  of  the  lens. 

(3)  Cataract,  which  afterwards  becomes  general,  may 
begin  as  a  thin  layer  at  the  middle  of  the  hinder  surface 
of  the  lens  (posterior  polar  cataract)  (Fig.  58).  There  are 
many  varieties,  but  in  general  the  pole  itself  shows  the 
most  change,  the  opacity  radiating  outwards  from  it  in 
more  or  less  regular  spokes.  The  color  appears  grayish, 
yellowish,  or  even  brown,  because  seen  through  the  whole 
thickness  of  the  lens.  Sometimes  the  opacity  is  situated 
really  just  behind  the  capsule,  i.  e.,  in  the  hyaloid  mem- 
brane or  front  of  the  vitreous ;  but  this  cannot  be  proved 
during  life.  Cataract  beginning  at  the  posterior  pole  is 
often  a  sign  of  disease  of  the  vitreous  depending  on  cho- 
roidal  disease ;  it  is  common  in  the  later  stages  of  retinitis 
pigmeutosa  and  severe  choroiditis,  and  in  high  degrees  of 
myopia  with  disease  of  the  vitreous.  The  prognosis,  there- 
fore, should  always  be  guarded  in  a  case  of  cataract  where 
the  principal  part  of  the  opacity  is  in  this  position. 

When  a  cataract  forms  without  known  connection  with 
other  disease  of  the  eye  it  is  said  to  be  "primary"  The 
term,  secondary  cataract  is  used  when  it  is  the  consequence 
of  some  local  disease,  such  as  severe  iridocyclitis,  glaucoma, 
detachment  of  the  retina,  or  the  growth  of  a  tumor  in  the 
eye.  The  pyramidal  cataract  is  strictly  a  secondary  form, 
though  not  usually  called  so.  Primary  cataract  is  almost 
always  symmetrical,  though  seldom  synchronous  in  the  two 
eyes;  whilst  secondary  cataract,  of  course,  may  or  may  not 
be  symmetrical. 

The  subjective  symptoms  of  cataract  depend  almost 
solely  on  the  obstruction  and  distortion  of  the  entering 
light  by  the  opacities.  Objectively  cataract  is  shown  in 


176  CATARACT. 

advanced  cases  by  the  white  or  gray  condition  of  the  pupil 
at  the  plane  of  the  iris ;  in  earlier  stages  by  whitish  opacity 
in  the  lens  when  examined  by  focal  illumination  (p.  60) 
and  by  corresponding  dark  portions  (lines,  spots,  or  patches) 
in  the  red  pupil  when  examined  by  the  ophthalmoscope 
mirror. 

Both  subjective  and  objective  symptoms  differ  with  the 
position  and  quantity  of  the  opacity.  When  the  whole 
lens  is  opaque,  the  pupil  is  uniformly  whitish ;  the  opacity 
lies  almost  on  a  level  with  the  iris,  no  space  intervening, 
and  consequently,  on  examining  by  focal  light,  we  find 
that  the  iris  casts  no  shadow  on  the  opacity ;  the  brightest 
light  from  the  mirror  will  not  penetrate  the  lens  in  quan- 
tity enough  to  illuminate  the  choroid,  and  hence  no  red 
reflex  will  be  obtained.  Such  a  cataract  is  said  to  be  ma- 
ture or  "ripe,"  and  the  affected  eye  will  be  in  ordinary 
speech  "blind."  If  both  are  equally  affected,  the  patient 
will  be  unable  to  see  any  objects;  but  he  will  distinguish 
quite  easily  between  light  and  shade  when  the  eye  is  alter- 
nately covered  and  uncovered  in  ordinary  daylight  (good 
perception  of  light,  p.  /.),  and  will  tell  correctly  the  position 
of  a  candle  flame. 

Diagnosis  of  Immature  and  Partial  Cataracts. 

The  patient  complains  of  gradual  failure  of  sight,  and 
we  find  the  acuteness  of  vision  (p.  43)  impaired  more  or 
less  (probably  more  in  one  eye  than  in  the  other).  In  the 
earliest  stages  of  senile  cataract  some  degree  of  myopia 
may  be  developed  (Chap.  XX.),  or  owing  to  irregular 
refraction  by  the  lens,  the  patient  may  see  two  or  more 
images  close  together  of  any  object  with  each  eye  (polyopia 
uniocularis).  If  he  can  still  read  moderate  type,  the  glasses 
appropriate  for  his  age  and  refraction,  though  giving  some 
help,  do  not  remove  the  defect,  whilst  for  distant  objects 


CATARACT.  177 

vision  is  worse  in  proportion  than  for  the  near  types.  If, 
as  is  usual,  he  be  presbyopic,  he  will  be  likely  to  choose 
over-strong  spectacles,  and  to  place  objects  too  close  to  his 
eyes,  so  as  to  obtain  larger  retinal  images,  and  thus  com- 
pensate for  want  of  clearness  (p.  26).  In  nuclear  cataract, 
as  the  axial  rays  of  light  are  most  obstructed,  sight  is  often 
better  when  the  pupil  is  rather  large,  and  such  patients  tell 
ua  that  they  see  better  in  a  dull  light  or  with  their  back  to 
the  window,  or  when  shading  the  eyes  with  the  hand.  In 
the  cortical  and  more  diffused  forms  this  symptom  is  less 
marked. 

On  examining  by  focal  light  (after  dilating  the  pupil 
with  atropine)  an  immature  nuclear  cataract  appears  as  a 
yellowish,  rather  deeply  seated  haze,  upon  which  a  shadow 
is  cast  by  the  iris  on  the  side  from  which  the  light  comes 
(3,  Fig.  56).  On  now  using  the  mirror,  this  same  opacity 

FIG.  56. 


Nuclear  cataract.  1.  Section  of  lens ;  opacity  densest  at  centre.  2. 
Opacity  seen  by  transmitted  light  (ophthalmoscope  mirror)  with  dilated 
pupil.  3.  Opacity  as  seen  by  reflected  light  (focal  illumination). 

appears  as  a  dull  blur  in  the  area  of  the  red  pupil,  darkest 
at  the  centre,  and  gradually  thinning  off  0:1  s:.l  sides,  so 
that,  at  the  margin  of  the  pupil,  the  full  red  choroidal 
reflex  may  still  be  present;  the  fundus  is  seen  as  through 
a  fog,  which  is  thickest  in  the  axis  of  vision,  so  that  by 
looking  through  the  more  lateral  parts  the  details  are  bet- 
ter seen  (2,  Fig.  56).  If  the  opacity  is  very  dense  and 
large,  only  a  faint  dull  redness  is  visible  quite  at  the  border 
of  the  pupil. 


178 


CATARACT. 


Cortical  opacities,  if  small  and  confined  to  the  equator 
(or  edge)  of  the  lens,  do  not  interfere  with  sight ;  they  are 
easily  detected  with  a  dilated  pupil  by  throwing  light  very 
obliquely  behind  the  iris.  When  large  and  encroaching 
on  the  pupil  they  are  visible  in  ordinary  daylight.  They 
occur  in  the  form  of  dots,  streaks,  or  bars ;  seen  by  focal 
light  they  are  white  or  grayish,  and  more  or  less  sharply 
defined,  according  as  they  are  in  the  anterior  or  posterior 
layers  (3,  Fig.  57).  With  the  mirror  they  appear  black 

FIG.  57. 


Cortical  cataract.     References  as  in  preceding  figure. 

or  grayish,  and  of  rather  smaller  size  (2,  Fig.  57),  and  if 
the  intervening  substance  is  clear,  the  details  of  the  fundus 
can  be  seen,  sharply  between  the  bars  of  opacity. 

Posterior  polar  opacities  are  seldom  visible  without  care- 
ful focal  illumination,  when  we  find  a  patchy  or  stellate 
figure  very  deeply  seated  in  the  axis  of  the  lens  (3,  Fig. 
58) ;  if  large,  it  looks  concave  like  the  bottom  of  a  shallow 

FIG.  58. 


Posterior  polar  cataract.     References  as  before. 

cup.  With  the  mirror  it  is  seen  as  a  dark  star  (2,  Fig.  58), 
or  network,  or  irregular  patch,  or  smaller  than  when  seen 
by  focal  light. 

The  diagnosis  of  lamellar  cataract  is  easy  if  its  nature  be 
understood,  but  by  beginners  it  is  often  diagnosed  as  "nu- 


CATARACT. 


179 


clear."  The  patients  are  generally  children  or  young 
adults;  they  complain  of  "near  sight"  rather  than  of 
"cataract;"  for  the  opacity  is  not  usually  very  dense,  and 
whether  the  refraction  of  their  eyes  be  really  myopic  or 
not,  they  (like  other  cataractous  patients)  compensate  for 
dull  retinal  images  by  holding  the  object  nearer,  and  so 
increasing  the  size  of  the  images.  The  acuteness  of  vision 
is  always  defective,  and  cannot  be  fully  remedied  by  any 
glasses.  They  often  see  rather  better  with  the  eyes  shaded 
(pupils  dilated),  or  after  the  use  of  atropine  aided  by  con- 
vex glasses  to  substitute  the  accommodation.  The  pupil 
presents  a  deeply  seated  slight  grayness  (4,  Fig.  59),  and 

FIG  59. 


Lamellar  cataract.  Figs.  1,  2,  3,  as  before.  Fig.  4  shows  slight  gray- 
ness  of  the  undilated  pupil,  owing  to  the  layers  of  opacity  being  deeply 
seated. 

when  dilated  with  atropine  the  outline  of  the  shell  of 
opacity  is  exposed  within  it.  It  is  sharply  defined  and 
circular,  and  by  focal  light  is  whitish,  interspersed  in  many 
cases  with  white  specks,  which  at  its  equator  appear  as 
little  projections  (3,  Fig.  59).  By  this  examination  we 
easily  make  out  that  the  opacity  consists  of  two  distinct 
layers,  that  there  is  a  layer  of  clear  lens  substance  (cortex) 
in  front  of  the  anterior  layer,  and  that  the  margin  (equator) 
of  the  lens  is  clear.  By  the  mirror  thfi  opacity  appears  as 
a  disk  of  nearly  uniform  grayish  or  dark  color,  sometimes 


180  CATARACT. 

with  projections,  or  darker  dots,  and  surrounded  by  a  zone 
of  bright  red  reflection  from  the  fundus  corresponding  to 
the  clear  margin  of  the  lens  (2,  Fig.  59).  The  opacity 
often  appears  rather  more  dense  just  at  its  boundary,  a 
sort  of  ring  being  formed  there.  In  some  cases  quite  large 
spicules  or  patches  project  from  the  margin  of  the  opacity. 
Not  only  does  the  size  of  the  opaque  lamella,  and,  there- 
fore, its  depth  from  the  surface  of  the  lens,  differ  greatly  in 
different  cases,  but  its  thickness  or  degree  of  opacity  varies 
also.  The  disease  is  nearly  always  exactly  symmetrical  in 
the  two  eyes.  Occasionally  there  are  two  shells  of  opacity, 
one  within  the  other,  separated  by  a  certain  amount  of 
clear  lens  substance. 

The  lens  may  be  cataractous  at  birth  (congenital  cataract). 
This  form,  of  which  there  are  several  varieties,  is  nearly 
always  symmetrical,  and  generally  always  involves  the 
whole  lens.  Often  the  development  of  the  eyeball  is  de- 
fective, and  though  there  are  no  synechise,  the  iris  often 
acts  badly  to  atropine. 

Traumatic  cataract. — Severe  blows  on  the  eye  may  be 
followed  by  opacity  of  the  lens,  the  suspensory  ligament 
being  generally  torn  in  some  part  of  its  circle  (concussion 
cataract),  but  I  am  not  aware  that  cataract  ever  follows 
injury  to  the  head  without  direct  injury  to  the  eye. 

Traumatic  cataract  proper  is  the  result  of  wound  of  the 
lens-capsule;  the  aqueous  passing  through  the  aperture  is 
imbibed  by  the  lens-fibres,  which  swell  up,  become  opaque, 
and  finally  disintegrate  and  are  absorbed.  The  opacity 
may  begin  within  a  few  hours  of  the  wound;  it  pro- 
gresses quickly  in  proportion  as  the  wound  is  large,  and 
the  patient  young.  The  older  the  patient  the  more  severe 
are  the  symptoms  likely  to  be,  and  the  worse  the  prognosis. 
A  free  wound  of  the  capsule  followed  by  rapid  swelling 
and  opacity  of  the  whole  lens,  in  an  adult  past  middle 
life,  may  give  rise  to  severe  glaucomatous  symptoms  and 


CATARACT.  181 

iritis.  In  from  three  to  six  months  the  wounded  lens  will 
generally  be  absorbed,  and  nothing  but  some  chalky-look- 
ing detritus  remain  in  connection  with  the  capsule.  A 
very  fine  puncture  of  the  lens  is  occasionally  followed  by 
nothing  more  than  a  small  patch  or  narrow  tract  of  opacity, 
or  by  very  slowly  advancing  general  haze. 

The  objects  of  treatment  are  to  prevent  iritis  and  poste- 
tior  synechise  by  atropine,  and  by  ice  and  leeching  if  there 
be  severe  inflammatory  symptoms.  "We  endeavor  to  wait 
for  the  natural  absorption  of  the  cataract,  being  prepared 
to  extract  the  lens  by  linear  operation  or  suction,  at  any 
time,  should  glaucoma,  iritis,  or  severe  irritation  arise. 

PROGNOSIS,  a.  Course. — Cataracts  advance  with  varying 
rapidity  in  different  cases.  As  a  rough  rule  the  progress 
of  a  general  cataract  is  rapid  in  proportion  to  the  youth 
of  the  patient.  Cataracts  in  old  people  commonly  take 
from  one  to  three  years  in  reaching  maturity — sometimes 
much  longer.  If  the  lens  be  allowed  to  remain  long 
after  it  is  opaque,  further  degenerative  changes  generally 
occur.  It  may  become  harder  and  smaller,  calcareous  and 
fatty  granules  being  formed  in  it ;  the  cortex  may  liquefy 
whilst  the  nucleus  remains  hard  (Morgagnian  cataract). 
A  soft  cataract  may  undergo  partial  absorption  and  shrink 
to  a  thin,  hard,  brittle  disk.  Soft  cataract  in  young  adults, 
whether  from  diabetes  or  not,  is  generally  complete  in  a 
few  months. 

b.  Sight. — The  prognosis  after  operation  is  good  when 
there  is  no  other  disease  of  the  eye,  and  when  the  patient 
(although  advanced  in  years)  is  in  fair  general  health.  It 
is  not  so  good  in  diabetes,  nor  when  the  patient  is  in  ob- 
viously bad  health,  the  eyes  being  then  less  tolerant  of 
operation.  In  lamellar,  and  especially  in  congenital  cases, 
it  must  be  guarded,  for  the  eyes  are  often  defective  in  other 
respects,  and  sometimes  very  intolerant  of  operation  ;  the 
intellect,  too,  is  sometimes  defective,  rendering  the  patient 

16 


182  CATARACT. 

less  able  to  make  proper  use  of  his  eyes.  In  traumatic 
cataract  of  course  everything  depends  on  the  details  of  the 
injury  (see  p.  166,  etc.),  but  in  general  the  younger  the 
patient  the  better  the  prospect  of  a  quiet  and  uncompli- 
cated absorption  of  the  lens. 

In  every  case  of  immature  cataract,  the  vitreous  and 
fundus  should  be  carefully  examined  by  the  ophthalmo- 
scope, and  the  refraction  ascertained.  The  presence  of 
high  myopia  is  unfavorable,  and  the  same  is  true  of  opaci- 
ties in  the  vitreous,  indicating,  as  they  usually  do,  that  it 
is  fluid.  Any  disease  of  the  choroid  or  retina  will,  of 
course,  act  injuriously  in  proportion  to  its  position  and  de- 
gree. In  every  case,  whether  complete  or  not,  the  size 
and  mobility  of  the  pupils  to  light  and  atropine  and  the 
tension  of  the  eye  are  to  be  carefully  noted. 

TREATMENT. — In  the  early  stages  of  senile  and  nuclear 
cataract  sight  is  improved  by  keeping  the  pupil  moderately 
dilated  with  a  weak  atropine  solution  (half  a  grain  to  the 
ounce),  used  about  three  times  a  week  (compare  p.  176). 
Dark  glasses,  by  allowing  some  dilatation  of  the  pupil, 
sometimes  give  relief.  Stenopaic  glasses  are  sometimes 
useful.  With  these  exceptions,  nothing  except  operative 
treatment  is  of  any  use.  The  management  of  lamellar 
cataract  requires  separate  description. 

Operations  for  the  removal  of  cataract  are  of  three 
kinds:  (1)  Extraction  of  the  lens  entire  through  a  large 
wound  in  the  cornea,  or  at  the  sclero-corneal  junction,  the 
lens-capsule  remaining  behind.  By  a  few  operators  the 
lens  is  removed  entire  in  its  capsule.  (2)  Gradual  absorp- 
tion of  soft  cataracts  by  the  action  of  the  aqueous  humor, 
admitted  through  needle  punctures  in  the  capsule,  just  as 
after  accidental  traumatic  cataract  (needle  operations,  so- 
lution, discission).  The  operation  needs  repetition  two  or 
three  times,  at  intervals  of  a  few  weeks,  and  the  whole 
process  therefore  spreads  over  three  or  four  months. 


CATARACT.  183 

(3)  For  soft  cataracts,  removal  by  a  suction  syringe  or 
curette,  introduced  into  the  anterior  chamber  through  a 
small  wound  near  the  margin  of  the  cornea,  the  whole  lens 
having  been  rendered  semifluid  by  a  free  discission  opera- 
tion, usually  a  few  days  previously.  (See  Operations.) 

Extraction  is  necessary  for  cataracts  after  about  the  age 
of  forty,  the  lens  from  this  age  onwards  being  so  firm  that 
its  absorption  after  discission  occupies  a  much  longer  time 
than  in  childhood  and  youth  ;  moreover,  as  the  swelling  of 
the  lens  after  puncture  by  the  needle  is  less  easily  borne  as 
age  advances,  solution  operations  become  not  only  slower, 
but  attended  by  more  danger  (p.  180).  Indeed,  extraction 
is  often  practised  in  preference  to  solution  much  earlier 
than  forty.  Suction  and  solution  operations  are  applicable 
up  to  about  the  age  of  thirty -five. 

The  suction  operation  is  difficult,  and  unless  well  per- 
formed is  attended  by  serious  risk  of  severe  iritis  and 
cyclitis.  Its  advantage,  as  compared  with  needle  opera- 
tions, lies  in  the  saving  of  time,  the  whole  lens  being  re- 
moved at  one  sitting. 

So  long  as  senile  cataract  is  single,  or,  if  double,  so  long 
as  the  second  eye  is  still  serviceable,  removal  of  the  cata- 
ract will  seldom  be  beneficial  to  the  patient;  unless  his 
health  be  likely  to  suffer  by  waiting  till  the  second  eye  is 
ready  and  his  prospect  of  a  good  result  to  be  thus  impaired. 
Indeed,  if  one  eye  be  still  fairly  good,  the  patient  will  often 
be  dissatisfied  by  finding  his  operated  eye  less  useful  than 
he  expected,  perhaps  even  not  so  useful  as  the  other.  But 
if  there  be  a  period  of  several  years  between  the  comple- 
tion of  cataract  in  the  first  eye  and  its  onset  in  the  other, 
the  first  may  have  become  over-ripe,  and  therefore  some- 
what less  favorable  for  operation,  if  we  wait  till  the  second 
eye  is  affected.  The  removal  of  a  single  cataract  in  young 
persons  is  often  expedient  on  the  ground  of  appearance,  or 
when  it  is  important  that  the  patient  should  not  have  a 


184  CATARACT. 

"blind  side."  In  all  cases  of  single  cataract  it  must  be 
explained  that  after  the  operation  the  two  eyes  will  not 
work  together,  on  account  of  the  extreme  difference  of  re- 
fraction. (See  Anisometropia.) 

Even  when  both  cataracts  are  mature  at  the  same  time, 
it  is  safer  to  remove  only  one  at  once,  because  the  after- 
treatment  is  more  easily  carried  out  upon  one  eye  than 
both,  and  because  after  double  operation  any  untoward 
result  in  one  eye  adds  to  the  difficulty  of  managing  its  fel- 
low ;  while  a  bad  result  after  single  extraction  enables  us 
to  take  especial  precautions,  and  to  modify  the  operation 
for  the  second  eye.  Even  if  the  patient  be  so  old  or  feeble 
that  the  second  eye  may  never  come  to  operation,  we  shall 
consult  his  interests  better  by  endeavoring  to  give  him  one 
good  eye  than  by  risking  a  bad  result  in  attempting  to  give 
him  both  at  the  same  time. 

The  principal  causes  of  failure  after  extraction  are : 

(1)  Hemorrhage  between  the  choroid  and  sclerotic,  com- 
ing on,  usually  with  severe  pain,  immediately  after  the 
operation.     The  blood  fills  the  eyeball,  and  often  oozes 
from  the  wound  and  soaks  through  the  bandage. 

(2)  Suppuration,  beginning  in  the  corneal  wound,  and 
in  most  cases  spreading  to  the  whole  cornea,  to  the  iris  and 
vitreous,  and  ending  in  a  total  loss  of  the  eye.     It  occasion- 
ally takes  a  less  rapid  course,  and  stops  short  of  a  fatal 
result.     The  alarm  is  given  in  from  twelve  hours  to  about 
three  days  after  operation  by  the  occurrence  of  pain,  in- 
flammatory oedema  of  the  lids  (particularly  the  free  border 
of  the  upper  lid),  and  the  appearance  of  some  muco-puru- 
lent  discharge.     On  raising  the  lid  the  eye  is  found  to  be 
greatly  congested,  its  conjunctiva  redematous,  the  edges  of 
the  wound  yellowish,  and  the  neighboring  cornea  steamy 
and  hazy.     In  very  rapid  cases  the  pupil,  especially  near 
to  the  wound,  may  already  be  occupied  by  lymph. 

The  energetic  use  of  hot  fomentations  for  an  hour,  three 


CATARACT.  185 

or  four  times  a  day,  and  the  constant  employment  between 
times  of  a  tight  compressive  bandage,  are  the  only  local 
means  likely  to  be  useful,  while  internally  full  doses  of 
quinine  with  ammonia,  and  wine  or  brandy,  should  be  at 
once  resorted  to.  But  the  great  majority  of  these  cases  go 
on  to  suppurative  panophthalmitis  or  to  severe  plastic 
irido-cyclitis  with  opacity  of  cornea  and  shrinking  of  the 
eyeball. 

(3)  Iritis  may  set  in  between  about  the  fourth  and  tenth 
days.     As  in  commencing  suppuration,  so  here  pain,  oedema 
of  the  lids,  and  chemosis  are  the  earliest  symptoms.    There 
is  lachrymation,  but  no  muco-purulent  discharge,  and  the 
cornea  and  wound  remain  clear  and  bright.     The  iris  is 
discolored    (unless   it   happen   to   be   naturally   greenish- 
brown),  and  the  pupil  dilates  badly  to  atropine.     When- 
ever in  a  case  presenting  such  symptoms  a  good  examina- 
tion is  rendered  difficult  on  account  of  the  photophobia,  iritis 
should  be  suspected.     If  the  early  symptoms  are  severe,  a 
few  leeches  to  the  temple  are  very  useful.     Atropine  and 
local  warmth  are  the  most  important  remedial  measures. 
If  atropine  after  a  time  causes  irritation  (p.  103),  daturine 
or  duboisine  should  be  tried  (F.  26,  27). 

This  inflammation  is  plastic,  ending  in  the  formation  of 
more  or  less  dense  membrane  which  occupies  the  area  of 
the  pupil,  and  often,  by  contracting  and  drawing  the  iris 
with  it  towards  the  operation  scar,  diminishes  and  displaces 
the  pupil.  (See  Iridotomy.)  The  membrane  is  often  dis- 
tinctly behind  the  iris  and  free  from  it ;  it  is  then  derived 
from  the  ciliary  processes  (irido-cyclitis). 

(4)  The  iris  may  prolapse  into  the  wound  at  the  opera- 
tion, or  a  few  days  afterwards  by  the  re-opening  or  yielding 
of  a  weakly  united  wound.     When  iridectomy  has  been 
done,  the  prolapse  appears  as  a  little  dark  bulging  at  one 
or  both  ends  of  the  wound,  and  often  causes  much  irrita- 
bility for  many  weeks  without  actual  iritis.     The  protrusion 

16* 


186  CATARACT. 

in  the  end  generally  flattens  down,  but  sometimes  it  needs 
to  be  punctured  or  even  removed.  The  occurrence  of  pro- 
lapse is  a  reason  for  keeping  the  eye  tied  up  longer.  After- 
operations  are  needed,  when  iritis  has  ended  in  more  or  less 
occlusion  and  contraction  of  the  pupil.  Nothing  should 
be  done  until  all  active  symptoms  have  subsided,  and  the 
eye  has  been  quiet  for  some  weeks. 

Sight  after  the  removal  of  cataract. — In  accounting  for 
the  state  of  the  sight,  we  have  to  remember  that  the  acute- 
ness  of  sight  naturally  decreases  in  old  age  (p.  43).  Again, 
slight  iritis  producing  a  little  filmy  opacity  in  the  pupil  is 
common  after  extraction.  Some  eyes  without  positive  in- 
flammation remain  irritable  long  after  the  operation,  so 
that  prolonged  use  is  impossible.  So  that,  putting  aside 
the  graver  complications,  we  find  that,  even  of  the  eyes 
which  do  best,  a  large  proportion  fail  to  reach  anything 
like  normal  acuteness  of  vision.  Cases  are  considered  good 
when  the  patient  can  with  his  glasses  read  anything  be- 
tween Nos.  1  and  14  Jaeger  and  T6^  Snellen;  but  a  much 
less  satisfactory  result  than  this  is  very  useful.  About  five 
per  cent,  of  the  eyes  operated  upon  are  lost  from  various 
causes.  The  eye  is  rendered  extremely  hypermetropic  by 
removal  of  the  lens,  and  strong  convex  glasses  are  neces- 
sary for  clear  vision.  They  should  seldom  be  allowed  until 
three  months  after  the  operation,  and  at  first  they  must  not 
be  continuously  worn.  Two  pairs  are  needed ;  one  making 
the  eye  emmetropic,  giving  clear  vision  of  distant  objects 
(+  10  or  11  D.),  the  other  (about  +  16  D.)  for  vision  of 
objects  at  a  short  distance  (8"  or  10"  =  20  or  25  cm.),  and 
representing  the  eye  when  strongly  accommodated.  As  all 
accommodation  is  lost,  the  patient  has  scarcely  any  range 
of  distinct  vision. 

Lamellar  cataract. — If  the  patient  can  see  enough  to 
get  on  fairly  well  at  school,  or  in  his  occupation,  it  is  best 
not  to  remove  the  lenses;  but  when  the  opacity  is  dense 


CATARACT.  187 

enough  to  seriously  interfere  with  the  patient's  prospects, 
something  must  always  be  done.  The  choice  lies  between 
the  artificial  pupil  when  the  margin  of  clear  lens  is  wide, 
and  solution  or  extraction  when  it  is  narrow,  or  when  large 
spicules  of  opacity  project  into  it  from  the  opaque  lamella. 
It  is  very  difficult  to  say  which  of  the  two  gives  on  the 
whole  the  better  results,  and  we  must  judge  each  case  on 
its  own  merits.  If  atropine,  by  dilating  the  pupil,  im- 
proves the  sight,  an  artificial  pupil,  made  by  removing  the 
iris  quite  up  to  its  ciliary  border,  will  generally  be  bene- 
ficial ;  the  clear  border  of  the  lens  is  thus  exposed  in  the 
coloboma,  and  light  passes  through  it  more  readily  than 
through  the  hazy  part.  A  very  good  rule  is  to  operate  on 
only  one  eye  at  a  time,  thus  allowing  the  choice  of  a  differ- 
ent operation  on  its  fellow. 

Secondary  cataracts  with  complete  blindness,  indicating 
deep  disease,  should  never  be  operated  upon. 

Dislocation  of  the  lens  in  its  capsule  is  usually  caused 
by  a  blow  on  the  eye,  but  may  be  spontaneous.  It  is  usu- 
ally downwards,  and  only  partial ;  the  iris  is  tremulous 
where  it  has  lost  support  (p.  162),  but  often  bulged  for- 
ward at  some  other  part ;  the  upper  edge  of  the  lens  can  be 
seen  through  the  dilated  pupil,  appearing  with  the  ophthal- 
moscope as  a  curved  black  line  across  the  field.  Such 
dislocation  may  cause  glaucoma.  The  lens  finally  often 
becomes  opaque.  More  rarely  the  transparent  lens  is  com- 
pletely dislocated  into  the  anterior  chamber ;  when  of  full 
size  it  causes  glaucoma,  but  if  shrunken,  may  remain  with- 
out doing  harm.  Sometimes  it  can  be  made  to  pass  at  will 
through  the  pupil  by  altering  the  position  of  the  head. 
The  edge  of  a  transparent  lens  in  the  anterior  chamber 
appears  as  a  bright  line  by  focal  illumination,  and  the  iris 
is  much  pushed  back — two  important  points  of  distinction 
from  "spongy"  exudation  in  iritis  (p.  136). 


188  DISEASES     OP     THE     CHOROID. 


CHAPTER   XIII. 

DISEASES    OF    THE    CHOROID. 

THE  choroid  is,  next  to  the  ciliary  processes,  the  most 
vascular  part  of  the  eyeball,  and  from  it  the  outer  layers 
of  the  retina,  and  probably  the  vitreous  humor  also,  mainly 
derive  their  nourishment.  Inflammatory  and  degenerative 
changes  often  occur,  some  of  them  entirely  local,  as  in 
myopia,  others  symptomatic  of  constitutional  or  of  gen- 
eralized disease,  such  as  syphilis  and  tuberculosis.  Choroi- 
ditis,  unlike  inflammation  of  its  continuations,  the  ciliary 
body  and  iris,  is  seldom  shown  by  external  congestion  or 
severe  pain  ;  and  as  none  of  its  symptoms  are  characteristic, 
its  diagnosis  rests  chiefly  on  ophthalmoscopic  evidence. 

Blemishes  or  scars,  permanent  and  easily  seen,  nearly 
always  follow  disease  of  the  choroid,  and  such  spots  and 
patches  are  often  as  useful  for  diagnosis  as  cicatrices  on  the 
skin,  and  deserve  as  careful  study.  The  retina  lying  over 
an  inflamed  choroid  often  takes  part  in  the  active  changes, 
or  atrophies  afterwards ;  but  in  other  cases,  apparently  as 
severe,  it  is  uninjured.  Indeed,  it  is  sometimes  far  from 
easy  to  say  in  which  of  these  two  structures  the  disease  has 
begun,  especially  as  changes  in  the  pigment  epithelium, 
which  is  really  part  of  the  retina,  are  as  often  the  result 
of  deep-seated  retinitis  or  retinal  hemorrhage  as  of  super- 
ficial choroiditis.  Patches  of  accumulated  pigment,  though 
usually  indicating  spots  of  former  choroiditis,  are  some- 
times the  result  of  bleeding,  either  from  retinal  or  choroidal 
vessels,  and  some  skill  is  needed  in  correctly  interpreting 
such  appearances. 


DISEASES    OF     THE     CHOROID.  189 

Appearances  in  health. — The  choroid  is  composed  chiefly 
of  bloodvessels  and  of  cells  containing  dark-brown  pig- 
ment. The  quantity  of  pigment  varies  much  in  different 
eyes,  and  to  some  degree  in  different  parts  of  the  same  eye ; 
it  is  very  scanty  in  early  childhood,  and  in  persons  of  fair 
complexion ;  more  abundant  in  persons  with  dark  hair  and 
brown  irides ;  more  plentiful  in  the  region  of  the  yellow 
spot  than  elsewhere.  In  old  age  the  pigment  epithelium 
becomes  paler.  When  examining  the  choroid,  we  need  to 
think  of  four  parts:  (1)  the  retinal  pigment  epithelium 
(which  is  for  ophthalmoscopic  purposes  choroidal),  recog- 
nized in  the  erect  image  as  a  fine  darkish  stippling ;  (2)  the 
capillary  layer  (chorio-capillaris),  just  beneath  the  epithe- 
lium, forming  a  very  close  mesh  work,  the  separate  vessels 
of  which  are  not  visible  in  life ;  (3)  the  larger  bloodvessels, 
often  easily  visible;  (4)  the  pigmented  connective-tissue 
cells  of  the  choroid  proper,  which  lie  amongst  the  larger 
vessels. 

In  the  majority  of  eyes  these  four  structures  are  so  toned 
as  to  give  a  nearly  uniform  full  red  color  by  the  ophthal- 
moscope, blood-color  predominating.  In  very  dark  races 
the  pigment  is  so  excessive  that  the  fundus  has  an  uniform 
slaty  color.  In  very  fair  persons  (and  young  children)  the 
deep  pigment  (4)  is  so  scanty  that  the  large  vessels  are 
separated  by  spaces  of  lighter  color  than  themselves  (Fig. 
31).  In  dark  individuals  these  intervascular  spaces  are 
of  a  deeper  hue  than  the  vessels,  the  latter  appearing  like 
light  streams  separated  by  dark  islands  (Fig.  62,  a).  Near 
to  the  disk  and  y.  s.  the  vessels  are  extremely  abundant 
and  very  tortuous,  the  interspaces  being  small  and  irregu- 
lar; but  towards  and  in  front  of  the  equator,  the  veins  take 
a  nearly  straight  course,  converging  to  their  exits  at  the 
vence  vorticosce,  and  the  islands  are  larger  and  elongated. 
The  veins  are  much  more  numerous  and  larger  than  the 
arteries  (Fig.  61),  but  no  distinction  can  be  made  between 


190  DISEASES     OF    THE    CHOROID. 

them  in  life.  The  vessels  of  the  choroid,  unlike  those  of 
the  retina,  present  no  light  streak  along  the  centre  (com- 
pare p.  71). 

The  pigment  epithelium  and  the  capillary  layer  tone 
down  the  above  contrasts,  and  so  in  old  age,  when  the  epi- 
thelial pigment  is  bleached,  and  again  when  the  capillary 
layer  is  atrophied  after  superficial  choroiditis  (Fig.  62,  a), 
the  distinctions  described  are  particularly  marked.  Fig. 
60  shows  a  vertical  section  of  naturally  injected  human 
choroid ;  the  uppermost  dark  line  is  the  pigment  epithelium 
(1) ;  next  are  seen  the  capillary  vessels,  cut  across  (2); 
then  the  more  deeply  seated  large  vessels  (3),  and  the  deep 
layer  of  stellate  pigment-cells  of  the  choroid  proper  (4). 
Fig.  61  is  from  an  artificially  injected  human  choroid  seen 
from  the  inner  surface.  The  shaded  portion  is  intended  to 
represent  the  general  effect  produced  by  all  the  vessels  and 
the  pigment  epithelium.  The  lower  part  shows  the  large 
vessels  with  their  elongated  interspaces,  as  may  be  seen  in 
a  case  where  the  pigment  epithelium  and  chorio-capillaris 
are  atrophied  (Fig.  62,  6) ;  in  a  dark  eye  these  interspaces 
would  be  darker  than  the  vessels.  The  middle  part  shows 
the  capillaries  without  the  pigment  epithelium.  Both  fig- 
ures are  magnified  about  four  times  as  much  as  the  image 
in  the  indirect  ophthalmoscopic  examination. 

'  FIG.  60. 


Human  choroid,  vertical  section.     Naturally  injected.     X  20. 

OPHTHALMOSCOPIC  SIGNS  OF  DISEASE  OF  THE  CHOROID. 

The  changes  usually  met  with  are  indicative  of  atrophy. 
This  may  be  partial  or  complete;  primary  or  following 
inflammation  or  hemorrhage;  in  circumscribed  spots  or 
patches,  or  in  large  and  less  abruptly  bounded  areas.  Sec- 


DISEASES    OF     THE     CHOROID. 


191 


ondary  changes  are  often  present  in  the  corresponding  parts 
of  the  retina.  The  chief  signs  of  atrophy  of  the  choroid 
are — (1)  the  substitution  of  a  paler  color  (varying  from  a 


FIG.  61. 


Vessels  of  human  choroid  artificially  injected.  Arteries  cross-shaded. 
Capillaries  too  dark  and  rather  too  small.  The  uppermost  shaded  part 
represents  the  effect  of  the  pigment  epithelium,  x  20. 

pale  red  to  a  full  paper-white),  for  the  full  red  of  health, 
the  subjacent  white  sclerotic  being  more  or  less  visible 
where  the  atrophic  changes  have  occurred ;  (2)  black  pig- 


192 


DISEASES     OF    THE    ClIORUil). 


ment  in  spots,  patches,  or  rings,  and  in  varying  quantity 
upon  or  around  the  pale  patches.  These  pigmentations 
result,  1st,  from  disturbance  and  heaping  together  of  the 
normal  pigment ;  2d,  from  increase  in  its  quantity ;  3d,  from 
blood-coloring  matter  left  after  extravasations.  Patches 
of  primary  atrophy  (e.  g.,  in  myopia)  are  never  much  pig- 
mented  unless  bleeding  have  taken  place,  The  amount  of 
pigmentation  in  atrophy  following  choroiditis  is  closely 
related  to  that  of  the  healthy  choroid,  i.  e.,  to  the  com- 
plexion of  the  person. 

FIG.  62. 


Atrophy  after  syphilitic  choroiditis,  showing  various  degrees  of  wasting 
Hutchinson).     a.  Atrophy  of  pigment  epithelium.     6.  Atrophy  of  epi- 
thelium  and  chorio-capillaris ;    the  large  vessels  exposed,     c.  Spots  of 
complete  atrophy,  many  with  pigment  accumulation. 

Pigment  in  the  fundus  may  lie  in  the  retina  as  well  as 
in  or  on  the  choroid,  and  this  is  true  whatever  may  have 
been  its  origin,  for  in  choroiditis  with  secondary  retinitis, 
the  choroidal  pigment  often  passes  fonvards  into  the  retina. 
When  a  spot  of  pigment  is  distinctly  seen  to  cover  over  a 


DISEASES     OF     THE     CHOKOID.  193 

retinal  vessel,  that  spot  must  be  not  only  in,  but  very  near 
the  anterior  (inner)  surface  of  the  retina ;  and  when  the 
pigment  has  a  linear,  mossy,  or  lace-like  pattern  (Fig.  72), 
it  is  always  in  the  retina ;  these  are  the  only  conclusive 
evidences  of  its  position. 

It  is  important  and  usually  easy  to  distinguish  between 
partial  and  complete  atrophy  of  the  choroid.  In  superficial 
atrophy  affecting  the  pigment  epithelium  and  capillary 
layer,  the  large  vessels  are  peculiarly  distinct  (Fig.  62,  a 
and  6).  Such  "  capillary  "  or  "  epithelial "  choroiditis  often 
covers  a  large  surface,  the  boundaries  of  which  are  some- 
times well  defined  and  sinuous  or  map-like,  but  are  as  often 
ill  marked  ;  in  the  latter  case  careful  comparison  between 
different  parts  of  the  fundus  is  necessary,  and  allowance 
must  be  made  for  the  patient's  age  and  complexion.  Coni- 

FIG.  63. 


Atrophy  after  choroiditis.    (Magnus.) 

plete  atrophy  is  shown  by  the  presence  of  patches  of  white 
or  yellowish- white  color  of  all  possible  variations  in  size, 
with  sharply  cut,  circular,  or  undulating  borders,  and  with 
or  without  pigment  accumulations  (Figs.  62,  c,  and  63).  The 
retinal  vessels  pass  unobscured  over  patches  of  atrophied 

17 


194  DISEASES    OF     THE     CHOROID. 

choroid,  proving  that  the  appearance  is  caused  by  some 
change  deeper  than  the  surface  of  the  retina. 

In  recent  choroiditis  we  also  often  see  patches  of  palish 
color,  but  they  are  less  sharply  bounded  and  frequently  of 
a  grayer  or  whiter  (less  yellow)  color  than  patches  of 
atrophy ;  moreover,  the  edge  of  such  a  patch  is  softened, 
the  texture  of  the  choroid  being  dimly  visible  there,  be- 
cause only  partly  veiled  by  exudation.  If  the  overlying 
retina  is  unaffected,  its  vessels  are  clearly  seen  over  the 
diseased  part;  but  if  the  retina  itself  is  hazy  or  opaque,  the 
exact  seat  of  the  exudation  often  cannot  be  at  once  decided. 
In  recent  cases  the  vitreous  too  is  often  hazy  or  full  of 

FIG.  64. 


Minute  exudations  into  inner  layer  of  choroid  in  syphilitic  choroiditis. 
Pigment  epithelium  adherent  over  the  exudations,  hut  elsewhere  has 
been  washed  off.  Ch.  Choroid;  Set.  Sclerotic. 

flocculi.  Most  commonly,  however,  patients  do  not  come 
until  the  exudation  stage  of  choroiditis  has  passed  into 
atrophy. 


Section  of  miliary  tuhercle.  Inner  layers  of  choroid  comparatively 
unaffected.  The  lighter  shading  surrounding  an  artery  in  the  deepest 
part  of  the  tubercle  represents  the  oldest  part,  which  is  caseating. 

Syphilitic  choroiditis  begins  in,  and  is  often  confined  to, 
the  inner  (capillary)  layer  of  the  choroid  (Fig.  64),  and 
hence  it  often  affects  the  retina.  In  miliary  tuberculosis  of 


DISEASES    OF     THE    CHOROID. 


195 


the  choroid  the  overlying  retina  is  clear,  and  the  growth  is, 
for  the  most  part,  deeply  seated  and  around  an  artery  (Fig. 
65).  After  very  severe  choroiditis,  or  extensive  hemor- 
rhage, the  absorption  may  be  incomplete;  in  addition  to 
atrophy,  we  then  see  gray  or  white  patches,  or  lines,  which, 
in  pattern  and  apparent  texture,  remind  us  of  scars  in  the 
skin,  or  of  patches  and  lines  of  old  thickening  on  serous 
membranes. 

Very  characteristic  changes  are  seen  after  rupture  of  the 
choroid  from  sudden  stretching  caused  by  blows  on  the  front 
of  the  eye.  These  ruptures,  always  situated  in  the  central 
region,  occur  in  the  form  of  long  tapering  lines  of  atrophy, 
usually  curved  slightly  towards  the  disk,  and  sometimes 
branched  (Fig.  66) ;  their  borders  are  often  pigmented. 

FIG.  66. 


Ruptures  of  Choroid.     CWecker.) 

If  seen  soon  after  the  blow,  the  rent  is  more  or  less  hidden 
by  blood,  and  the  retina  over  it  is  hazy. 

The  pathological  condition  known  as  "  colloid  disease  " 
of  the  choroid  consists  in  the  growth  of  very  small  nodules, 
soft  at  first,  afterwards  becoming  hard  like  glass,  from  the 


196  DISEASES     OF     THE    CHOROID. 

thin  lamina,  elastica,  which  lies  between  the  pigment  epi- 
thelium and  chorio-capillaris.  It  is  common  in  eyes  excised 
for  old  inflammatory  mischief,  and  in  partial  atrophy  after 
choroiditis  (Fig.  67).  But  little  is  known  of  its  ophthalmo- 
scopic  equivalent,  or  its  clinical  characters.  Probably  it 
may  result  from  various  forms  of  choroiditis,  and  may  also 
be  a  natural  senile  change. 

FIG.  67. 


Partial  atrophy  after  syphilitic  choroiditis.  Minute  growths  from  inner 
surface  of  choroid,  showing  how  they  disturb  the  outer  layers  of  the 
retina.  X  60. 

Hemorrliage  from  the  choroidal  vessels  is  not  so  often 
recognized  as  from  those  of  the  retina,  but  may  be  seen 
sometimes,  especially  in  old  people  and  in  highly  myopic 
eyes.  The  patches  are  more  rounded  than  retinal  hemor- 
rhages, and  it  is  often  possible  to  recognize  the  striation  of 
the  overlying  retina.  Occasionally  they  are  of  immense  size. 

CLINICAL  FORMS  OF  CHOROIDAL  DISEASE. 

(1)  Numerous   discrete   patches   of  choroidal   atrophy 
(sometimes  complete,  as  if  a  round  bit  had  been  punched 
out,  in  others  incomplete,  though  equally  round  and  well 
defined)  are  scattered  in  different  parts  of  the  fundus,  but 
are  most  abundant  towards  the  periphery ;  or,  if  scanty,  are 
found  only  in  the  latter  situation.     They  are  more  or  less 
pigmented,  unless  the  patient's  complexion  is  extremely 
fair  (Figs.  62,  c,  and  63). 

(2)  The  disease  has  the  same  distribution,  but  the  patches 
are  confluent ;  or  large  areas  of  incomplete  atrophy,  pass- 


DISEASES    OF    THE    CHOROID.  197 

ing  by  not  very  well-defined  boundaries  into  the  healthy 
choroid  around,  are  interspersed  -with  a  certain  number  of 
separate  patches ;  or  without  separate  patches  there  may 
be  a  widely  spread  superficial  atrophy  with  pigmentation 
(Fig.  62,  a  and  6). 

These  two  types  of  choroiditis  disseminata,  run  into  one 
another,  different  names  being  used  by  authors  to  indicate 
topographical  varieties.  Generally  both  eyes  are  affected, 
though  unequally ;  and  in  some  cases  one  escapes.  The 
retina  and  disk  often  show  signs  of  past  or  present  inflam- 
mation. 

Syphilis  is  almost  invariably  the  cause  of  symmetrical 
disseminated  choroiditis.  The  choroiditis  begins  from  one 
to  three  years  after  the  primary  disease,  whether  this  be 
acquired  or  inherited  ;  occasionally  at  a  later  period. 

The  discrete  variety  (Fig.  62,  c),  where  the  patches, 
though  usually  involving  the  whole  thickness  of  the  choroid, 
are  not  connected  by  areas  of  superficial  change,  is  the  less 
serious  form,  unless  the  patches  are  very  abundant.  A 
moderate  number  of  such  patches  confined  to  the  periphery, 
cause  no  appreciable  damage  to  sight. 

The  more  superficial  and  widely  spread  varieties,  in 
which  the  retina  and  disk  are  inflamed  from  the  first,  are 
far  more  serious.  The  capillary  layer  of  the  choroid  sel- 
dom again  becomes  healthy,  and  with  its  atrophy,  even  if 
the  deeper  vessels  be  not  much  changed,  the  retina  suffers, 
passing  into  slowly  progressive  atrophy.  The  retina  often 
becomes  pigmented  (Fig.  72),  its  bloodvessels  extremely 
narrowed,  and  the  disk  passes  into  a  peculiar  hazy  yellowish 
atrophy  ("  waxy  disk  " — Hutchinson, "  choroiditic  atrophy  " 
— Gowers).  The  appearances  may  closely  imitate  those  in 
true  retinitis  pigmentosa,  and  the  patient,  as  in  that  disease, 
often  suffers  from  marked  night-blindness.  Such  cases  con- 
tinue to  get  worse  for  many  years,  and  may  become  nearly 
blind. 

17* 


198  DISEASES    OF     THE    CHOROID. 

Syphilitic  choroiditis  generally  gives  rise,  at  an  early 
date,  to  opacities  in  the  vitreous ;  they  are  either  of  large 
size  and  easily  seen  as  slowly  floating  ill-defined  clouds,  or 
so  minute  and  numerous  as  to  cause  a  diffuse  and  somewhat 
dense  haziness  ("dust-like  opacities,"  Forster)  (see  p.  251). 
Some  of  the  larger  ones  may  be  permanent.  In  the  ad- 
vanced stages,  as  in  true  retinitis  pigmentosa,  posterior  polar 
cataract  is  sometimes  developed. 

There  are  no  constant  differences  between  choroiditis  in 
acquired  and  in  inherited  syphilis  ;  in  many  cases  it  would 
be  impossible  to  guess,  from  the  ophthalmoscopic  changes, 
with  \vhich  form  of  the  disease  we  had  to  do.  But  there 
is,  on  the  whole,  a  greater  tendency  towards  pigmentation 
in  the  choroiditis  of  hereditary  than  in  that  of  acquired 
syphilis,  and  this  applies  both  to  the  choroidal  patches  and 
to  the  subsequent  retinal  pigmentation. 

In  the  treatment  of  syphilitic  choroiditis  we  rely  almost 
entirely  on  the  constitutional  remedies  for  syphilis — mer- 
cury and  iodide  of  potassium.  Cases  which  are  treated 
early  in  the  exudation  stage  are  very  much  benefited  in 
sight  by  mercury,  the  visible  exudations  quickly  melting 
away ;  but  I  believe  that  even  in  these  complete  restitution 
seldom  takes  place,  the  nutrition  and  arrangement  of  the 
pigment  epithelium  and  baeillary  layer  of  the  retina  being 
quickly  and  permanently  damaged  by  exudations  into  or 
upon  the  chorio-capillaris  (as  in  Fig.  64).  In  the  later 
periods,  when  the  choroid  is  thinned  by  atrophy,  or  its 
inner  surface  roughened  by  little  outgrowths  (Fig.  67),  or 
adhesions  and  cicatricial  contractions  have  occurred  be- 
tween it  and  the  retina,  nothing  can  be  done.  A  long 
mercurial  course  should,  however,  always  be  tried  if  the 
sight  be  still  failing,  even  if  the  changes  all  look  old ;  for 
in  some  cases,  even  of  very  long  standing,  fresh  failure 
takes  place  from  time  to  time,  and  internal  treatment  has 
a  very  marked  influence.  In  acute  cases  it  is  well  to  pre- 


DISEASES     OF     THE    CHOROID.  199 

scribe  also  rest  of  the  eyes  in  a  dark  room,  and  the  em- 
ployment of  the  artificial  leech  or  of  dry  cupping  at  in- 
tervals of  a  few  days,  for  some  weeks.  But  it  is  often 
difficult  to  insure  such  functional  rest,  for  the  patients 
seldom  have  pain  or  other  discomfort. 

(3)  The  choroidal  disease  is  limited  to  the  central  region. 
There  are  many  varieties  of  such  localized  change. 

In  myopia  the  elongation  which  occurs  at  the  posterior 
pole  of  the  eye  very  often  causes  atrophy  of  the  choroid 
contiguous  to  the  disk,  and  usually  only  on  the  side  next 
the  yellow  spot  (p.  291).  The  term  "posterior  staphyloma" 
is  applied  to  this  form  of  disease  when  the  eye  is  myopic, 
because  the  atrophy  is  a  sign  of  posterior  bulging  of  the 
sclerotic.  The  term  "  sclerotico-choroiditis  posterior  "  is  also 
used.  A  similar,  but  narrow  and  less  conspicuous  crescent 
or  zone  of  atrophy  around  the  disk  is  seen  in  some  other 
states  without  myopia,  notably  in  old  persons,  and  in  glau- 
coma (Fig.  81).  Separate  round  patches  of  complete 
atrophy  ("punched-out"  patches)  at  the  central  region 
may  accompany  the  commoner  changes  in  myopia,  and 
must  not  then  be  ascribed  to  syphilitic  choroiditis ;  more 
commonly  in  myopia  ill-defined  partial  atrophy  is  seen 
about  the  y.  s.,  sometimes  with  splits  or  lines  running  hori- 
zontally towards  this  part  from  the  disk. 

Central  senile  choroiditis. — Several  varieties  of  disease 
confined  to  the  region  of  the  y.  s.  and  disk  are  seen,  and 
chiefly  in  old  persons.  A  particularly  striking  and  rather 
rare  form  is  shown  in  Fig.  68.  In  others  a  larger,  but  less 
defined,  area  is  affected.  Some  of  these  appearances  un- 
doubtedly result  from  large  choroidal  or  retinal  extrava- 
sations, but  the  nature  of  the  disease  in  such  as  Fig.  68  is 
obscure.  In  another  form,  along  with  superficial  atrophy, 
the  large  deep  vessels  are  much  narrowed,  or  even  con- 
verted into  white  lines  and  devoid  of  blood  column,  by 
thickening  of  their  coats.  In  another  form  the  central 


200  DISEASES    OF    THE     CHOKOID. 

region  is  occupied  by  a  number  of  very  small,  white,  or 
yellowish-white  dots,  sometimes  visible  only  in  the  erect 
image.  This  form  in  typical  cases  is  very  peculiar,  and 
appears  to  be  almost  stationary ;  the  disks  are  often  de- 
cidedly pale ;  when  very  abundant  the  spots  coalesce,  and 
some  pigmentation  is  found.  The  pathological  anatomy 

FIG.  67. 


Central  choroiditis.     (Wecker  and  Jaeger.) 

and  general  relations  of  this  disease  are  incompletely 
known  ;  it  has  been  clinically  described  by  Hutchinson 
and  Tay,  and  is  tolerably  common.  It  is  symmetrical,  and 
the  changes  may  sometimes  be  mistaken  for  a  slight  albu- 
minuric  retinitis  (see  p.  94).  No  treatment  seems  to  have 
any  in-fluence.  Every  case  of  immature  cataract  should, 
when  possible,  be  examined  for  central  choroidal  changes. 

(4)  Anomalous  forms  of  choroidal  disease. — Single, 
large  patches  of  complete  atrophy,  with  pigmentation,  and 
not  located  in  any  particular  part,  are  occasionally  met 
with.  There  is  reason  to  believe  that  some  of  them  have 


DISEASES    OF     THE     CHOKOID.  201 

followed  the  absorption  of  tubercular  growths  in  the  cho- 
roid,  while  others  are  the  result  of  single  large  hemorrhages 
(p.  196).  Single  large  patches  of  exudation  are  also  met 
with,  and  are  perhaps  tubercular  (see,  also,  p.  149).  Gen- 
eralized choroidal  disease  in  patches  sometimes  occurs  in 
persons  who  have  certainly  not  had  syphilis.  I  believe 
that  in  most  of  these  the  disease  is  due  to  numerous  scat- 
tered hemorrhages  into  the  choroid,  sometimes  occurring 
repeatedly  at  different  dates;  and  leading  to  patches  of 
partial  atrophy  with  pigmentation.  The  local  cause  of  the 
hemorrhage  is  obscure ;  the  disease  often  affects  only  one 
eye,  and  is  generally  seen  in  young  males.  It  may  perhaps 
be  called  hemorrhagic  choroiditis  (compare  p.  254  (4)). 
Although  the  changes  produced  are  very  gross,  some  of 
these  patients  regain  almost  perfect  sight,  a  fact,  perhaps, 
pointing  to  the  deep  layers  of  the  choroid  as  the  seat  of 
disease. 

Single  spots  of  choroidal  atrophy,  especially  towards  the 
periphery,  should,  no  less  than  abundant  changes,  always 
excite  grave  suspicion  of  former  syphilis,  and  often  furnish 
valuable  corroborative  evidence  of  that  disease  (compare 
Myopic  Changes).  The  periphery  cannot  be  fully  exam- 
ined unless  the  pupil  be  widely  dilated.  A  few  small, 
scattered  spots  of  black  pigment  on  the  choroid  or  in  the 
retina,  without  evidence  of  atrophy  of  the  choroid,  often 
indicate  former  hemorrhages.  Such  spots  are  seen  after 
recovery  from  albuminuric  retinitis  with  hemorrhages,  after 
blows  on  the  eye,  and  sometimes  without  any  relevant 
history. 

Congestion  of  the  choroid  is  not  commonly  recognizable 
by  the  ophthalmoscope.  That  active  congestion  does  occur 
is  certain,  and  it  would  seem  that  myopic  eyes  are  espe- 
cially liable  to  it,  particularly  when  exposed  to  bright 
light  and  great  heat.  Serious  hemorrhage  may  undoubt- 
edly be  excited  under  such  circumstances.  In  conditions 


202  DISEASES    OF     THE    CHOROID. 

of  extreme  anaemia  the  whole  choroid  becomes  unmistak- 
ably pale. 

Coloboma  of  the  choroid  (congenital  deficiency  of  the 
lower  part)  is  shown  ophthalmoscopically  by  a  large  sur- 
face of  exposed  sclerotic,  often  embracing  the  disk  (which 
is  much  altered  in  form,  and  may  be  hardly  recognizable), 
and  extending  downwards  to  the  periphery,  where  it  often 
narrows  to  a  mere  line  or  chink.  The  surface  of  the  scle- 
rotic, as  judged  by  the  course  of  the  retinal  vessels,  is  often 
very  irregular,  from  bulging  of  its  floor  backwards.  The 
coloboma  is  occasionally  limited  to  the  part  around  the 
nerve,  or  may  form  a  separate  patch.  Coloboma  of  the 
choroid  is  often  seen  without  coloboma  of  the  iris,  and 
when  both  exist,  a  bridge  of  choroidal  tissue  generally 
separates  them  in  the  region  of  the  ciliary  body. 

Albinism  is  accompanied  by  congenital  absence  of  pig- 
ment in  the  cells  of  the  pigment  epithelium  and  stroma  of 
the  whole  uveal  tract  (choroid,  ciliary  processes,  and  iris). 
The  pupil  looks  pink  because  the  fundus  is  lighted,  to  a 
great  extent,  indirectly  through  the  sclerotic.  Sight  is 
always  defective,  and  the  eyes  photophobic  and  usually 
oscillating.  Many  almost  albinotic  children  become  mod- 
erately pigmented  as  they  grow  up. 


DISEASES     OF     THE    RETINA.  203 


CHAPTER    XIV. 

DISEASES    OF    THE    RETINA. 

OF  the  many  morbid  changes  to  which  the  retina  is 
subject,  some  begin  and  end  in  this  membrane,  such  as 
albuminuric  retinitis  and  many  forms  of  retinal  hemor- 
rhage ;  in  others,  the  retina  takes  part  in  changes  which 
begin  in  the  optic  nerve  (neuro-retinitis),  or  in  the  choroid 
(choroido-retinitis) ;  very  serious  lesions  also  occur  from 
embolism  or  thrombosis  of  the  central  retinal  vessels.  The 
retina  may  be  separated  ("  detached ")  from  the  choroid 
by  blood  or  other  fluid.  The  retina  may  also  be  the  seat 
of  malignant  growth  (glioma),  and  probably  of  tubercular 
inflammation. 

In  health  the  human  retina  is  so  nearly  transparent  as 
to  be  almost  invisible  by  the  ophthalmoscope  during  life, 
or  to  the  naked  eye  if  examined  immediately  after  excision. 
We  see  the  retinal  bloodvessels,  but  the  retina  itself,  as  a 
rule,  we  do  not  see.  The  main  bloodvessels  are  derived 
from  the  arteria  and  vena  centralis,  which  enter  the  outer 
side  of  the  optic  nerve,  about  6  mm.  behind  the  eye,  and 
except  close  to  the  disk,  they  are  smaller  and  much  less 
abundant  than  those  of  the  choroid  (Fig.  31) ;  the  veins 
and  arteries  are  generally  in  pairs,  the  veins  not  being 
more  numerous  than  the  arteries ;  all  pass  from  or  to  the 
optic  disk.  At  the  disk  anastomoses,  chiefly  capillary,  are 
formed  between  the  vessels  of  the  retina  and  those  of  the 
choroid  and  sclerotic.  As  no  other  anastomoses  are  formed 
by  the  vessels  of  the  retina,  the  retinal  circulation  beyond 
the  disk  is  terminal ;  and,  further,  as  the  vessels  branch 


204  DISEASES     OF     THE     RETINA. 

dichotomously,  and  the  branches  anastomose  only  by  means 
of  their  capillaries,  the  circulation  of  each  considerable 
branch  is  terminal  also.  The  capillaries,  which  are  not 
visible  by  the  ophthalmoscope,  are  narrower  and  much  less 
abundant  (except  just  at  the  y.  s.  region)  than  those  of  the 
choroid  (compare  Figs.  61  and  69),  their  meshes  becoming 
wider  and  wider  towards  the  anterior  and  less  important 
parts  of  the  retina.  They  are  most  abundant  at  the  y.  s. 
region,  the  only  part  used  for  accurate  vision ;  the  very 
centre  of  this  region  (fovea  centralu'),  however,  where  all 
the  layers  except  the  cones  and  outer  granules  are  exces- 
sively thin,  contains  no  vessels,  the  capillaries  forming  fine 
close  loops  just  around  it  (Fig.  69). 

FIG.  69. 


rsiN  r.2O 

Bloodvessels  of  human  retina  at  the  yellow  spot  (artificial  injection). 
The  central  gap  corresponds  to  the  fovea  centralis.  A.  Arteries ;  v.  Veins ; 
N.  Nasal  side  (towards  disk) ;  T.  Temporal  side. 

In  children,  especially  those  of  dark  complexion,  a 
peculiar  and  striking  whitish  shifting  reflection,  or  shimmer, 
is  often  seen  at  the  yellow  spot  region  and  along  the  course 
of  the  principal  vessels.  It  changes  with  every  movement 
of  the  mirror,  and  reminds  one  of  the  shifting  reflection 
from  "watered  '  and  "shot"  silk.  Around  the  yellow  spot 
it  takes  the  form  of  a  ring  or  zone,  and  is  known  as  the 


DISEASES     OF     THE     KETINA.  205 

"halo  round  the  macula"  (p.  71).  When  the  choroid  is 
highly  pigmented,  even  if  this  shifting  reflection  be  absent, 
the  retina  is  visible  as  a  faint  haze  over  the  choroid  like 
the  "bloom"  on  a  plum.  Under  the  high  magnifying 
power  of  the  erect  image  the  nerve-fibre  layer  is  often 
visible  near  the  disk,  as  a  faintly  marked  radiating  striation. 
The  sheaths  of  the  large  central  vessels  at  their  emergence 
from  the  physiological  pit  (p.  69)  show  many  variations  in 
thickness  and  opacity. 

In  rare  cases  the  medullary  sheath  of  the  optic  nerve- 
fibres,  which  should  cease  at  the  lamina  cribrosa,  is  con- 
tinued up  to  or  reproduced  at  the  disk,  especially  at  its 
margin,  and  causes  the  ophthalmoscopic  appearance  known 
as  "  opaque  nerve-fibres."  This  congenital  peculiarity  may 
affect  the  nerve-fibres  of  the  whole  circumference  of  the 
disk  or  only  a  patch  or  tuft  of  the  fibres ;  it  may  only  just 
overleap  the  edge  of  the  disk,  or  may  extend  far  into  the 
retina,  where  even  separate  islands  of  opacity  are  some- 
times seen.  It  is  to  be  particularly  noted  that  the  central 
part  (physiological  pit)  of  the  disk  is  never  affected,  be- 
cause it  contains  no  nerve-fibres.  The  affected  part  is  pure 
white,  and  quite  opaque ;  at  its  margin  the  patch  thins  out 
gradually,  and  is  striated  in  fine  lines,  which  radiate  from 
the  disk  like  carded  cotton-wool ;  the  retinal  vessels  may 
be  buried  in  the  opacity,  or  run  unobscured  on  its  surface, 
and  are  of  normal  size.  The  deep  layers  of  the  affected 
part  of  the  retina  being  obscured  by  the  opacity,  an  en- 
largement of  the  normal  "  blind-spot "  is  the  result.  One 
or  both  eyes  may  be  affected.  There  is  seldom  any  diffi- 
culty in  distinguishing  this  condition  from  opacity  due  to 
neuro-retinitis. 


18 


206  DISEASES    OF    THE    RETINA. 


OPHTHALMOSCOPIC  SIGNS  OF  RETINAL  DISEASE. 

Congestion. — No  amount  of  capillary  congestion,  whether 
passive  or  active,  alters  the  appearance  of  the  retina  ;  and 
as  to  the  large  vessels,  it  is  better  to  speak  of  the  arteries 
as  unusually  large  or  tortuous,  or  of  the  veins  as  turgid  or 
tortuous,  than  to  use  the  general  term  congestion.  Capil- 
lary congestion  of  the  optic  disk  may  undoubtedly  be  recog- 
nized ;  but  even  here  great  caution  is  needed,  and  much 
allowance  must  be  made  for  differences  of  contrast  depend- 
ing on  the  depth  of  tint  of  the  choroid,  for  the  patient's 
health  and  age,  and  for  the  brightness  of  the  light  used,  or, 
what  is  the  same  thing,  for  the  size  of  the  pupil.  Caution 
is  also  needed  against  drawing  hasty  inferences  from  the 
slight  haziness  of  the  outline  of  the  disk,  which  may  often 
be  seen  in  cases  of  hypermetropia,  and  which  is  certainly 
not  always  morbid. 

The  only  ophthalmoscopic  evidence  of  true  retinitis  is 
loss  of  transparency  of  the  retina,  and  two  chief  types  are 
soon  recognized  according  as  the  opacity  is  diffused,  or  con- 
sists chiefly  of  abrupt  spots  and  patches.  Hemorrhages  are 
present  in  many  cases  of  retinitis ;  but  they  are  also  com- 
mon in  cases  where  there  is  no  true  inflammation.  The 
state  of  the  disk  varies  much,  but  it  seldom  escapes  entirely 
in  a  case  of  extensive  or  prolonged  retinitis.  In  a  large 
majority  of  cases  of  recent  retinitis  the  visible  changes  are 
limited  to  the  central  region,  where  the  retina  is  thickest 
and  most  vascular. 

(1)  The  lessened  transparency  which  accompanies  dif- 
fused retinitis  simply  dulls  the  red  choroidal  reflex,  and 
the  term  "  smoky  "  is  fairly  descriptive  of  it.  The  same 
effect  is  given  by  slight  haziness  of  any  of  the  anterior 
media,  but  a  mistake  is  excusable  only  when  there  is  dif- 
fused mistiness  of  the  vitreous  from  opacities  which  are  too 


DISEASES    OF     THE    RETINA  207 

small  to  be  easily  distinguished  (pp.  251  and  253),  and  the 
difficulty  is  then  increased  because  this  very  condition  of 
the  vitreous  often  coexists  with  retinitis.  A  comparison  of 
the  erect  and  inverted  images  is  often  useful,  for  if  the 
diffused  haze  noticed  by  indirect  examination  be  caused  by 
retinitis,  then  by  the  direct  examination  what  before  seemed 
a  uniform  haze  may  now  appear  as  well-marked  spotting 
or  streaking.  When  the  change  is  pronounced  enough  to 
cause  a  decidedly  white  haze  of  the  retina  there  is  no 

FIG.  70. 


Renal  retinitis  at  a  late  stage.     (Wecker  and  Jaeger.) 

longer  any  doubt.  The  retinal  arteries  and  veins  are  some> 
times  enlarged  and  tortuous  in  retinitis,  and  in  severe  cases 
they  are  generally  obscured  in  some  part  of  their  course. 
These  diffused  forms  are  usually  caused  either  by  syphilis 
or  embolism. 

(2)  The  retina  generally  is  clear,  but  near  the  yellow 
spot  a  number  of  small,  intensely  white,  rounded  spots  are 
seen  (Fig.  70),  either  quite  discrete  or  partly  confluent. 


208 


DISEASES    OP     THE    RETINA. 


When  very  abundant  and  confluent  they  form  large,  ab- 
ruptly outlined  patches,  often  with  crenated  borders ;  or 
some  parts  may  be  striated  and  others  stippled. 

(3)  A  number  of  separate  patches  are  scattered  about 
the  central  region,  but  without  special  reference  to  the 
yellow  spot.  They  are  of  irregular  shape,  white  or  pale 
buff,  and  sometimes  striated ;  they  are  easily  distinguished 
from  patches  of  choroidal  atrophy  (p.  190)  by  their  color, 
the  comparative  softness  of  their  outlines,  and  the  absence 
of  pigmentation. 

In  the  last  two  forms,  hemorrhages  are  usually  present 
also. 

FIG.  71. 


Recent  severe  retinitis  in  renal  disease.      (Gowers.) 

(4)  There  are  numerous  hemorrhages,  with  general  hazi- 
ness intensified  at  places  into  distinct,  but  not  abruptly 
defined,  patches  of  white  or  yellowish-white ;  the  retinal 
vessels  are  extremely  tortuous,  and  the  veins  dilated 
(Fig.  71). 

Forms  2  and  3  are  generally  associated  with  albuminuria, 


DISEASES    OF    THE    EETINA.  209 

but  in  rare  cases  similar  changes  are  caused  by  cerebral 
disease.     The  changes  are  always  nearly  symmetrical. 

(5)  Rarely  a  single  large  patch  or  area  of  white  opacity 
is  seen  with  softened,  ill-defined  edges,  any  retinal  vessels 
that  may  cross  it  being  obscured.  In  most  cases  such  a 
patch  of  retinitis  is  caused  by  choroidal  exudation  beneath 
(p.  194). 

Hemorrhage  into  (or  beneath)  the  retina  is  known  by 
its  color,  which  is  darker  than  that  of  the  average  choroid ; 
but  redder  and  lighter  than  that  of  a  very  dark  choroid. 
Blood  may  be  effused  into  any  of  the  retinal  layers,  and 
the  shape  of  the  blood  patches  is  mainly  determined  by 
their  position.  When  effused  into  the  nerve-fibre  layer,  or 
confined  by  the  sheath  of  a  large  vessel,  the  extravasation 
takes  a  linear  or  streaked  form  and  structure,  following  the 
direction  of  the  nerve-fibres  ;  extravasations  in  the  deeper 
layers  are  generally  rounded  or  irregular.  Very  large 
hemorrhages,  many  times  as  large  us  the  disk,  sometimes 
occur  near  the  yellow  spot,  and  probably  all  the  layers  then 
become  infiltrated,  while  sometimes  the  blood  ruptures  the 
anterior  limiting  membrane  of  the  retina  and  passes  into 
the  vitreous. 

Retinal  hemorrhages  may  be  large  or  small,  single  or 
multiple ;  limited  to  the  central  region  or  scattered  in  all 
parts  ;  linear,  streaky,  or  flame-shape,  punctate  or  blotchy ; 
they  may  lie  alongside  large  vessels,  or  be  in  no  apparent 
relation  to  visible  vessels.  The  hemorrhage  may,  as  already 
mentioned,  be  the  primary  change  or  may  only  form  part 
of  a  retinitis  or  papillo-retinitis.  A  hemorrhage  which  is 
mottled  and  of  dark,  dull  color  is  generally  old.  The  rate 
of  absorption  varies  very  greatly  ;  hemorrhages  after  blows 
are  very  quickly  absorbed,  while  those  depending  on  rupture 
of  diseased  vessels  in  old  people,  or  accompanying  albu- 
minuric  retinitis,  generally  last  for  months,  and  often  leave 
permanent  traces. 

18* 


210  DISEASES     OF     THE    RETINA. 

Pigmentation  of  the  retina  lias  been  referred  to  in  con- 
nection with  choroiditis  (p.  191).  Whenever  pigment  in 
the  fundus  forms  long,  sharply  defined  lines,  or  is  arranged 
in  a  mossy,  lace-like,  or  reticulated  pattern,  we  may  always 
safely  infer  that  it  is  situated  in  the  retina,  and  generally 
that  it  lies  along  the  sheaths  of  the  retinal  vessels  (com- 
pare Fig.  72  with  Fig.  69).  Pigment  in  or  on  the  choroid 
never  takes  such  a  pattern,  being  usually  in  blotches  or 
rings.  The  two  types,  however,  are  often  mingled  in  cases 
of  choroiditis  with  secondary  affection  of  the  retina ;  in- 
deed, in  every  case  where  we  decide  that  the  retina  is  pig- 

FIG.  72. 


Study  of  pigment  in  the  retina  in  a  specimen  of  secondary  retinitis 
pigmentosa,  seen  from  the  inner  (vitreous)  surface. 

mented  the  choroid  must  be  carefully  examined  for  evi- 
dences of  former  choroiditis. 

Spots  of  pigment  are  not  unfrequently  left  after  the  ab- 
sorption of  retinal  hemorrhages.  It  is  seldom  difficult  to 
distinguish  these  spots  from  those  which  follow  choroiditis; 
they  are  uniformly  black  or  dark  brown,  and  though  some- 
times surrounded  by  a  little  collar  of  pale  choroid,  or  by 
some  disturbance  of  the  pigment  epithelium,  they  are  not 
associated  with  any  other  signs  of  choroidal  disease  (com- 
pare Choroidal  Hemorrhage,  pp.  184  and  189). 

Atrophy  of  the  retina,  of  which  pigmentation,  when 
present,  is  always  a  sign,  has  for  its  most  constant  indica- 
tion a  marked  shrinking  of  the  retinal  bloodvessels  and 
thickening  of  their  coats.  When  the  atrophy  follows  a 
retinitis  or  choroido-retinitis  (retinitis  pigmentosa,  syphilitic 
choroido-retinitis,  etc.)  all  the  layers  are  involved,  and  the 


DISEASES    OF    THE    RETINA.  211 

outer  layers  (those  nearest  the  choroid)  earlier  than  the 
inner ;  but  when  it  is  secondary  to  disease  of  the  optic  nerve 
(optic  neuritis,  progressive  atrophy,  and  glaucoma)  only 
the  layers  of  nerve-fibres  and  ganglion  cells  are  atrophied, 
the  outer  layers  being  found  perfect  even  after  many  years. 
A  retina  atrophied  after  retinitis  often  does  not  regain  per- 
fect transparency,  and  if  there  have  been  choroiditis  the 
retina  remains  especially  hazy  in  the  parts  where  this  has 
been  most  severe. 

The  disk  in  atrophy  following  retinitis  or  choroido- 
retinitis  always  passes  into  atrophy,  often  of  peculiar  ap- 
pearance, being  pale,  hazy,  but  homogeneous  looking,  with 
a  yellowish  or  brownish  tint  (p.  197). 

Detachment  (separation)  of  the  retina. — As  there  is  no 
continuity  of  structure  between  the  choroid  and  retina, 
the  two  may  be  easily  separated  by  hemorrhage,  effusion 

FIG.  73. 


Faction  of  eye  with  partial  detachment  of  retina. 

of  fluid,  and  morbid  growths.  This  result  is  very  seldom 
caused  by  primary  changes  in  the  retina,  but  nearly  always 
depends  upon  disease  of  the  choroid,  ciliary  body,  or 
vitreous.  The  retina  is  separated  at  the  expense  of  the 
vitreous  (which  is  proportionately  absorbed),  but  always 
remains  attached  at  the  disk  and  ora  serrata,  unless  as  the 
result  of  wound  or  great  violence.  The  depth,  area,  and 
situation  of  the  detachment  are  subject  to  much  variety. 
Fig.  73  shows  a  diagrammatic  section  of  an  eye  in  which 
the  lower  part  of  the  retina  is  separated. 


212  DISEASES     OF     THE     KETINA. 

The  separated  portion  is  usually  far  within  the  focal 
length  of  the  eye,  its  erect  image  is,  therefore,  very  easily 
visible  by  the  direct  method  (p.  73,  1),  when  it  appears  as 
a  dark,  or  gray,  or  whitish  reflection  in  some  part  of  the 
field,  the  remainder  being  of  the  proper  red  color;  the  de- 
tached part  is  gray  or  whitish,  because  the  retina  has  be- 
come opaque.  With  care  we  can  accurately  focus  the 
surface  of  the  gray  reflection,  see  that  it  is  folded,  and  sec 
one  or  more  retinal  vessels  meandering  upon  it  in  a  tortu- 
ous course;  they  appear  small  and  of  dark  color.  If  the 
separation  be  deep,  the  outline  of  its  more  prominent  folds 
^Fig,  74)  can  be  seen  standing  out  sharply  against  the  red 

FIG.  74. 


Ophthalmoscopic  appearance  of  detached  retina  (erect  image). 
(After  Wecker  and  Jaeger.) 

background,  and  in  some  cases  the  folds  flap  about  when 
the  eye  is  quickly  moved.  In  extreme  cases  we  can  see 
the  detached  part  by  focal  light.  When  the  detachment 
is  recent,  especially  if  shallow,  the  red  choroid  is  still  seen 
through  it ;  the  diagnosis  then  rests  on  the  observation  of 
whether  the  vessels  in  any  part  become  darker,  smaller, 
and  more  tortuous,  and  upon  ophthalmoscopic  estimation 
of  the  refraction  of  the  retinal  vessels  (p.  75)  at  different 
parts  of  the  fundus,  for  the.  detached  part  will  be  much 
more  hypermetropic  than  the  rest.  In  very  high  myopia, 
a  shallow  detachment  may  still  lie  behind  the  principal 
focus,  and  therefore  not  yield  an  erect  image  without  a 


DISEASES     OF     THE     KETINA.  213 

suitable  convex  lens.  In  such  cases,  and  in  others  where 
minute  rucks  or  folds  of  detachment  are  present,  examina- 
tion by  the  indirect  method  leads  to  a  right  diagnosis  ;  the 
image  of  the  detached  portion  is  not  in  focus  at  the  same 
moment  as  its  surrounding  parts,  parallactic  movement1  is 
obtained,  and  the  vessels  are  tortuous.  Deep  and  extensive 
detachment  is  often  associated  with  opacities  in  the  vitreous 
or  lens,  or  with  iritic  adhesions.  All  or  any  of  these  con- 
ditions interfere  with  the  conclusive  application  of  the 
above  tests,  for  the  full  use  of  which  a  dilated  pupil  is 
often  essential.  The  common  causes  of  detachment  are 
injury,  myopia,  and  intraocular  tumors.  Its  treatment  is 
very  unsatisfactory.  Puncture  of  the  sclerotic  over  the 
detachment,  or  of  the  separated  retina  itself,  allowing  the 
fluid  to  escape  from  the  eye  in  the  one  case  or  into  the 
vitreous  in  the  other,  have  been  repeatedly  tried.  Lately 
profuse  sweating  and  salivation  induced  by  pilocarpine 
(Fig.  33,  A)  have  been  recommended  in  recent  cases. 

CLINICAL  FORMS  OF  RETINAL  DISEASE. 

The  symptoms  of  retinal  disease  relate  only  to  the  failure 
of  sight  which  they  cause,  and  this  may  be  either  general 
or  confined  to  a  part  of  the  field,  according  to  the  nature 
of  the  case.  Neither  photophobia  nor  pain  occurs  in  un- 
complicated retinitis. 

Syphilitic  retinitis  is  generally  associated  with  and  sec- 
ondary to  choroiditis  (p.  197),  but  in  a  few  cases  retinitis 
of  quite  the  same  character  is  primary.  The  vitreous  in 
this  disease,  as  in  syphilitic  choroiditis,  is  often  hazy,  and 
the  opacities  are  sometimes  seated  very  deeply,  just  in  front 
of  the  retina.  The  changes  are  those  of  diffuse  retinitis 
(p.  206,  1),  with  slight  "smoky"  haze,  often  confined  to 

1  On  closing  one  eye  and  viewing  two  objects,  one  beyond  the 
other  but  in  the  same  line,  one  object  seems  to  move  over  the  other 
when  the  head  is  moved  from  side  to  side. 


214  DISEASES     OF    THE     RETINA. 

the  yellow  spot  or  disk  region ;  but  in  bad  cases  the  haze 
passes  into  a  whiter  mistiness,  and  extends  over  a  much 
larger  region ;  sometimes  long  branching  streaks  or  bands 
of  dense  opacity  are  met  with,  and  hemorrhages  may  occur. 
The  disk  is  always  hazy,  and  at  first  decidedly  too  red, 
while  the  retinal  vessels,  both  arteries  and  veins,  are  some- 
what turgid  and  tortuous.  In  a  few  the  disk  becomes 
opaque  and  swollen  (papillitis).  At  a  late  period  in  un- 
favorable cases  the  vessels  shrink  slowly,  almost  to  threads, 
and  the  retina  often  becomes  pigmented  at  the  periphery. 

Syphilitic  retinitis  is  one  of  the  secondary  symptoms, 
seldom  setting  in  earlier  than  six,  or  later  than  eighteen, 
months  after  the  primary  disease.  It  occurs  in  congenital 
as  well  as  acquired  syphilis.  It  generally  attacks  both 
eyes,  though  often  with  an  interval.  Its  onset  is  often 
rapid,  as  judged  by  its  chief  symptom,  failure  of  sight,  and 
it  may  be  stated  that,  as  a  rule,  the  degree  of  amblyopia 
is  much  greater  than  would  be  expected  from  the  ophthal- 
moscopic  changes.  Night-blindness  is  always  a  pronounced 
symptom.  It  is  essentially  a  protracted  disease,  always 
lasting  for  months,  and  showing  a  remarkable  tendency 
for  many  months  to  repeated  and  rapid  exacerbations  after 
temporary  recoveries,  but  with  a  tendency  to  get  worse 
rather  than  towards  spontaneous  cure.  Amongst  the  early 
symptoms  is  often  a  "flickering,"  and  this  with  the  history 
of  variations  lasting  for  a  few  days,  and  of  marked 
night-blindness,  often  lead  to  a  correct  surmise  before 
ophthalmoscopic  examination.  There  is,  however,  nothing 
pathognomonic  in  any  of  the  symptoms.  An  annular 
defect  in  the  visual  field  ("  ring  scotoma  ")  may  often  be 
found  if  sought;  in  the  late  stages  the  field  is  contracted. 

Mercury  produces  most  marked  benefit,  and  when  used 
early  it  permanently  cures  a  large  proportion  of  the  cases ; 
but  in  a  number  of  cases,  perhaps  in  those  where  there  is 
most  choroiditis,  the  disease  goes  slowly  from  bad  to  worse 


DISEASES     Of     T1IE     RETINA.  215 

for  several  years,  in  spite  of  very  prolonged  mercurial 
treatment.  Of  the  efficacy  of  prolonged  disuse  of  the  eyes, 
and  of  local  counter-irritation  or  depletion,  strongly  rec- 
ommended by  many  authors,  I  have  had  but  little  ex- 
perience. 

Albuminuric  retinitis  (papillo-retinitis). — The  changes 
are  strongly  marked,  and  so  characteristic  that  it  is  possible, 
in  most  cases,  to  say  from  an  ophthalmoscopic  examination 
alone  that  the  patient  is  suffering  from  chronic  kidney 
disease. 

The  earliest  change  (the  stage  of  oedema  and  exudation) 
is  a  general  haze  of  a  dull  or  grayish  tint  in  the  central 
region  of  the  retina,  generally  with  some  hemorrhages  and 
soft-edged  white  patches  (3  and  4,  p.  208),  and  with  or 
without  haze  and  swelling  of  the  disk.  In  this  stage  the 
sight  is  often  unimpaired,  and  so  the  cases  are  seldom  seen 
by  ophthalmic  surgeons  till  a  few  weeks  later,  when  the 
translucent,  probably  albuminous,  exudations  into  the 
swollen  retina  have  passed  into  fatty  or  fibrinous  degenera- 
tion, affecting  both  the  nerve-fibres  and  connective  tissue 
of  the  retina. 

In  this,  the  second  stage,  we  find  a  number  of  pure  white 
dots,  spots,  or  patches,  in  the  hazy  region,  and  especially 
grouped  around  the  yellow  spot.  Their  peculiarity  is 
their  sharp  definition  and  pure  opaque  white  color,  which 
is  almost  glistening  when  they  are  small  and  round.  When 
not  very  numerous,  they  are  generally  confined  to  the 
yellow  spot  region,  from  which  they  show  a  tendency  to 
radiate  in  lines  (Fig.  70);  when  very  small  and  scanty 
they  may  be  overlooked,  unless  we  employ  the  erect  image ; 
but  in  most  cases  large  patches  are  formed  by  the  con- 
fluence of  small  spots,  and  the  borders  of  these  patches  are 
striated,  crenated,  or  spotted.  At  this  stage  the  soft-edged 
patches  (Fig.  71)  have  often  to  a  great  extent  disappeared 
or  become  merged  into  more  general  opacity  of  the  retina ; 


216  DISEASES     OF     THE     RETINA. 

the  disk  is  hazy  and  somewhat  swollen,  especially  just  at 
its  margin,  and  the  retina,  as  judged  by  the  undulations  of 
its  vessels,  and  confirmed  by  post-mortem  examinations,  is 
much  thickened.  Hemorrhages  are  generally  still  present 
in  greater  or  less  number,  and  occasionally  constitute  the 
most  marked  feature  of  the  case;  they  are  usually  striated. 
Sometimes  an  artery  is  seen  sheathed  by  a  dense  white 
coating.1  In  another  group  papillitis  (p.  225)  is  the  most 
marked  change,  though  some  bright  white  retinal  spots 
are  always  to  be  found  by  careful  examination. 

The  usual  tendency  is  towards  subsidence  of  the  oedema, 
and  absorption  of  the  fatty  deposits  and  extravasations, 
generally  with  improvement  of  sight — the  third  stage,  or 
stage  of  absorption  and  atrophy.  In  the  course  of  several 
months  the  white  spots  diminish  in  size  and  number  until 
only  a  few  very  small  ones  are  left  near  the  yellow  spot, 
with,  perhaps,  some  residual  haze;  the  blood-patches  are 
slowly  absorbed,  often  leaving  pigment  spots,  and  the  re- 
tinal arteries  may  be  shrunken.  In  cases  of  only  moderate 
severity  almost  perfect  sight  is  restored.  But  when  the 
optic  disk  suffers  severely  (severe  papillitis),  or  if  the  re- 
tinal disease  is  excessive  and  attended  by  great  oedema, 
sight  either  improves  very  little,  or,  as  the  disk  passes  into 
atrophy  and  the  retinal  vessels  contract,  it  may  sink  to 
almost  total  blindness.  Such  a  condition  may  be  mistaken 
for  atrophy  after  cerebral  neuritis ;  but  the  presence  of  a 
few  minute  bright  dots  or  of  some  superficial  disturbance 
of  the  choroid  at  the  yellow  spot,  or  of  some  scattered 
pigment  spots  left  by  extravasations,  will  generally  lead  to 
a  correct  inference  (p.  210).  In  the  cases  attended  by  the 
greatest  swelling  and  opacity  of  retina  and  disk,  death 
often  occurs  before  retrogressive  changes  have  taken  place. 

1  An  excellent  illustration  of  this  is  given  in  Dr.  Gower's  Medi- 
cal Ophthalmoscopy,  pi.  xii.,  Fig.  1. 


DISEASES     OF    THE     RETINA.  217 

Albuminuric  retinitis  is  symmetrical,  but  seldom  quite 
equal  in  degree  or  result  in  the  two  eyes.  In  extreme  cases 
it  may  cause  detachment  of  the  retina. 

The  kidney  disease  in  the  malady  under  consideration 
is  always  chronic.  The  retinitis  may  occur  in  any  chronic 
nephritis,  and  in  the  albuminuria  of  pregnancy.  What- 
ever be  the  form  of  the  kidney  disease,  the  retinitis  seldom 
occurs  without  other  signs  of  active  kidney  mischief,  such 
as  headache,  vomiting,  loss  of  appetite,  and  often  anasarca. 
The  quantity  of  albumen  varies  very  much.  In  the  ab- 
sence of  anasarca  the  symptoms  are  often  put  down  to 
"  biliousness,"  and  as  in  such  cases  the  failure  of  sight  is 
the  most  troublesome  symptom,  the  ophthalmoscope  often 
leads  to  the  correct  diagnosis.  Many  of  the  best  marked 
cases  of  albuminuric  retiuitis  occur  in  the  albuminuria  of 
pregnancy,  and  the  prognosis  for  sight  is  good  in  many  of 
these  if  the  symptoms  come  on  late  in  the  pregnancy.  On 
the  other  hand,  some  of  them  (probably  cases  of  old 
kidney  disease)  do  very  badly,  and  pass  into  atrophy  of 
the  nerves.  A  second  attack  of  retinitis  sometimes  occurs 
in  connection  with  a  relapse  of  renal  symptoms. 

(For  the  changes  which  occur  in  the  retina  in  other 
chronic  general  diseases,  e.  g.,  diabetes,  pernicious  anaemia, 
and  leucocythaemia,  see  Chapter  on  Etiology.) 

The  term  retinitis  haemorrhagica  has  been  given  to 
certain  rare  cases,  where  very  numerous  small  linear  or 
flame-shaped  retinal  hemorrhages  are  found  all  over  the 
fundus,  with  extreme  venous  engorgement.  It  usually 
occurs  in  only  one  eye  at  a  time,  and  comes  on  rapidly. 
The  patients  are  often  gouty.  Thrombosis  of  the  trunk 
of  the  -vena  centralis  retime  is  probably  the  determining 
cause  of  the  condition.1 

Other  cases  are  seen  where  extravasations,  varying  much 

1  Hutchinson  ;  Michel,  Graefe's  Arch,  of  Ophth.,  xxiv.  2. 
19 


218  DISEASES    OP    THE    RETINA. 

in  size,  number,  and  shape,  are  scattered  in  different  parts 
of  the  fundus  of  one  or  both  eyes.  Some  of  them  are 
probably  allied  to  the  above,  but  often  the  nature  of  the 
case  is  obscure,  or  the  hemorrrhages  are  related  to  senile 
degeneration  of  vessels.  Such  cases  are  often  called  retinitis 
apoplectica. 

Lastly,  in  an  important  group,  a  single  very  large  ex- 
travasation occurs  from  rupture  of  a  large  retinal  vessel, 
probably  an  artery.  The  hemorrhage  is  generally  in  the 
yellow  spot  region  ;  in  process  of  absorption  it  becomes 
mottled,  the  densest  parts  remaining  longest,  and,  if  seen 
in  that  condition  for  the  first  time,  the  case  may  be  taken 
for  one  of  multiple  hemorrhages.  These  large  extravasa- 
tions cause  great  defect  of  sight,  which  comes  on  in  an  hour 
or  two,  but  not  with  absolute  suddenness.  Absorption,  in 
all  the  groups  of  cases  above  mentioned,  is  very  slow. 

Hemorrhages  may  occur  from  blows  on  the  eye.  They 
are  usually  small  and  quickly  absorbed,  differing  in  the 
latter  respect  very  much  from  the  cases  before  described. 

Embolism  of  the  central  artery  of  the  retina,  or  of  one 
or  more  of  its  main  divisions,  gives  rise  to  a  characteristic 
retinitis,  the  cause  of  which  can  in  most  cases  be  recog- 
nized at  once  if  it  be  recent;  whilst  in  old  cases  the  ap- 
pearances, taken  with  the  history,  always  lead  to  a  right 
diagnosis.  Thrombosis  of  the  artery  causes  similar  changes. 

The  leading  symptom  of  embolism  is  the  occurrence  of 
an  instantaneous  defect  of  sight,  which  is  found  on  trial  to 
be  limited  to  one  eye;  sometimes  the  feeling  is  as  if  one 
eye  had  suddenly  become  "shut,"  the  blindness  being  as 
sudden  as  that  from  quickly  closing  the  lids ;  but  whether 
the  defect  amounts  to  absolute  blindness  or  not,  depends  on 
the  position  and  size  of  the  plug.  In  any  case,  owing  to 
the  temporary  establishment  of  collateral  circulation  by 
the  capillary  anastomoses  at  the  disk  (p.  203),  the  patient 
often  notices  an  improvement  of  sight  a  few  hours  after  the 


DISEASES     OF     THE     RETINA.  219 

occurrence.  But  this  improvement  is  only  very  slight,  the 
collateral  channels  being  quite  insufficient  to  meet  the  de- 
mand promptly;  n.or  is  it  often  permanent,  because  the 
retina  suffers  very  quickly  from  the  almost  complete  stasis, 
oedema  and  inflammation  rapidly  setting  in  and  leading  to 
permanent  damage. 

If  the  case  be  seen  within  a  few  days  of  the  occurrence, 
the  red  reflex  of  the  choroid  around  the  yellow  spot  and 
disk  is  quite  obscured,  or  partially  dulled,  by  a  diffused 
and  uniform  white  mist  The  opacity  is  greatest  just 
around  the  centre  of  the  yellow  spot,  where  the  retina  is 
very  vascular  (Fig.  69),  and  where  its  cellular  elements 
(ganglion  and  granule  layers)  are  more  abundant  than  any- 
where else;  but  at  the  very  centre  of  the  white  mist  a 
small,  round,  red  spot  is  generally  seen,  so  well  defined  that 
it  may  be  mistaken  for  a  hemorrhage;  it  represents  the 
fovea  centralis,  where  the  retina  is  so  thin  that  the  choroid 
.continues  to  shine  through  it  when  the  surrounding  parts 
are  opaque;  it  is  spoken  of  by  authors  as  the  "cherry-red 
spot  at  the  macula  lutea."  This  appearance  is  very  seldom 
seen  except  after  sudden  arrest  of  arterial  blood  supply,  by 
embolism  or  thrombosis  of  the  arteria  centralis,  and  per- 
haps by  hemorrhage  into  the  optic  nerve  compressing  the 
vessels;  and  of  these  causes  embolism  appears  to  be. the 
commonest.  The  haze  surrounds  and  generally  affects  the 
disk  also,  which  soon  becomes  very  pale.  The  small  veins 
in  the  yellow  spot  region  often  stand  out  with  great  dis- 
tinctness, partly  because  enlarged  by  stasis,  and  partly  from 
contrast  with  the  white  retina.  Small  hemorrhages  are 
often  present.  The  larger  retinal  vessels,  both  arteries  and 
veins,  are  more  or  less  diminished  at  and  near  the  disk,  the 
arteries  in  the  most  typical  cases  being  reduced  to  mere 
threads;  while  both  arteries  and  veins  are  sometimes  ob- 
served to  increase  in  size  as  they  recede  from  the  disk. 
The  arteries,  however,  are  not  always  extremely  shrunken 


220  DISEASES    OF    THE    RETINA. 

in  cases  of  retinal  embolism,  the  variations  depending  upon 
the  position  and  size  of  the  plug,  i.  e.,  upon  whether  it 
causes  complete  occlusion  or  not.  The  sudden  and  com- 
plete failure  of  supply  to  a  branch  of  a  retinal  artery  is 
sometimes  followed  by  its  emptying  and  shrinking  to  a 
Avhite  cord  almost  immediately.  In  other  cases  a  large 
artery  may  for  a  time  be  little,  if  at  all,  altered  in  size  and 
yet  its  blood  column  be  quite  stagnant,  as  is  proved  by  the 
impossibility  of  producing  pulsation  in  it  by  the  firmest 
pressure  on  the  globe,  whilst  the  other  branches  respond 
perfectly  to  this  test  (p.  72).  But  in  other  cases,  this 
pressure  test,  which  showed  blockage  of  some  or  all 
branches  shortly  after  the  onset,  again  produces  pulsation 
a  few  days  later,  without  any  visible  evidence  of  collateral 
circulation. 

In  from  one  to  about  four  weeks  the  cloudiness  clears 
off,  and  the  disk  passes  into  moderately  white  atrophy ;  the 
arteries,  or  some  of  them  (according  to  the  position  of  the 
plugging),  are  either  reduced  to  bloodless  white  lines,  or 
are  simply  narrowed  considerably,  but  still  pulsate  easily 
on  pi-ess  u  re. 

Sight  is  always  extinguished,  or  only  perception  of  large 
objects  remains,  whatever  be  the  final  state  of  the  blood- 
vessels. In  the  rare  cases,  where  an  embolus  passes  beyond 
the  disk,  and  is  arrested  in  a  branch  at  some  distance  from 
it,  the  changes  are  confined  to  the  corresponding  sector  of 
the  retina,  and  a  limited  defect  of  the  field  is  the  only  result. 
It  is  scarcely  necessary  to  say  that  no  treatment  can  be  of 
any  use  in  cases  of  lasting  occlusion  of  the  retinal  arteries. 

In  a  few  cases  where  instantaneous  blindness  of  both  eyes 
has  been  associated  with  extremely  diminished  arteries 
("ischcemia  retince"^),  iridectomy  has  been  followed  by 
return  of  sight;  lower  tension  causing  reestablishment  of 
circulation.  These  cases  generally  occur  after  whooping- 
cough.  (See  also  Quinine  Blindness.) 


DISEASES     OF     THE     RETINA.  221 

Retinitis  pigmentcsa  is  a  very  slowly  progressive  sym- 
metrical disease,  leading  to  atrophy  of  the  retina,  with 
collection  of  black  pigment  in  its  layers  and  around  the 
bloodvessels,  and  secondary  atrophy  of  the  disk. 

The  earliest  symptom  is  inability  to  see  well  at  night  or 
by  artificial  light  (night-blindness,  nyctalopia).  Concentric 
contraction  of  the  visual  field  soon  occurs.  These  defects 
may  reach  a  high  degree,  whilst  central  vision  remains  ex- 
cellent in  bright  daylight.  The  symptoms  are  noticed  at 
an  earlier  stage  by  patients  in  whom  the  choroid  is  dark 
and  absorbs  much  light. 

Ophthalmoscopic  examination,  where  these  symptoms 
have  been  present  for  some  years,  shows :  (1)  at  the  equator 
or  periphery  a  greater  or  less  quantity  of  pigment  arranged 
in  a  reticulated  or  linear  manner  (Fig.  72),  often  with 
some  small  separate  dots ;  (2)  in  advanced  cases,  evidence 
of  removal  of  the  pigment  epithelium,  but  never  any 
patches  of  choroidal  atrophy;  (3)  that  the  pigment  is 
arranged  in  a  belt,  which  is  in  general  terms  uniform,  the 
pattern  being  most  crowded  at  the  centre  and  thinning  out 
towards  the  borders  of  the  belt;  (4)  that  the  changes  are 
always  symmetrical,  and  the  symmetry  very  precise.  These 
appearances  are  quite  characteristic  of  true  retinitis  pig- 
mentosa.  In  addition  we  find  (5)  diminution  in  size  of  the 
retinal  bloodvessels,  the  arteries  in  advanced  cases  being 
mere  threads;  (6)  a  peculiar  hazy,  yellowish,  "waxy" 
pallor  of  the  optic  disk  (p.  211);  (7)  sometimes  the  pig- 
mented  parts  of  the  retina  are  quite  hazy;  (8)  posterior 
polar  cataract  and  disease  of  the  vitreous  are  often  present 
in  the  later  stages.  The  latter  changes  (5  to  8),  however, 
are  found  in  many  cases  of  late  retinitis  consecutive  to 
choroiditis,  and  are  not  peculiar  to  the  present  malady. 

The  disease  begins  in  childhood  or  adolescence,  progresses 
slowly  but  surely,  and  as  a  rule  ends  in  blindness  some 
time  after  middle  life.  A  few  cases  of  apparently  recent 

19* 


222  DISEASES     OF    THE     RETINA. 

origin  are  seen  in  quite  aged  persons,  and  a  few  are  con- 
sidered to  be  truly  congenital.  The  quantity  of  pigment 
visible  by  the  ophthalmoscope  varies  much  in  cases  of 
apparently  equal  duration,  and  is  not  in  direct  relation  to 
the  defect  of  sight;  cases  even  occur  which  certainly 
belong  to  the  same  category  in  which  no  pigment  is  visible 
during  life,  the  retina  being  merely  hazy,  and  in  one  such 
case  microscopical  examination  revealed  abundance  of 
minutely  divided  pigment  (Poncet).  The  pathogenesis  of 
the  disease  is  not  finally  settled ;  it  is  at  present  doubtful 
whether  there  is  from  the  first  a  slow  sclerosis  of  the  con- 
nective-tissue elements  of  the  retina,  with  passage  inwards 
of  pigment  from  the  pigment  epithelium,  or  whether  the 
disease  begins  in  the  superficial  layers  of  the  choroid  and 
the  pigment  epithelium.  Its  cause  is  obscure.  It  is  un- 
doubtedly strongly  heritable,  and  many  high  authorities 
believe  that  it  is  really  produced  by  consanguinity  of 
marriage,  either  between  the  parents,  or  near  ancestors  of 
the  affected  persons.  Many  of  its  subjects  are  of  full 
mental  and  bodily  vigor;  but  others  are  badly  grown, 
suffer  from  progressive  deafness,  and  are  defective  in  intel- 
lect. Although  want  of  education,  as  a  consequence  of 
defective  sight  and  hearing,  may  sometimes  account  for 
this  result,  we  cannot  thus  explain  the  various  defects  and 
diseases  of  the  nervous  system  which  are  not  unfrequently 
noticed  in  kinsmen  of  the  patients.  That  the  subjects  of 
this  disease  should  be  discouraged  from  marrying  is  suf- 
ficiently evident. 

In  a  few  cases  galvanism  has  been  followed  by  improve- 
ment both  of  vision  and  visual1  field,  but  no  other  treat- 
ment has  any  influence. 

Complications  such  as  cataract  and  myopia  are  not  un- 
common, and  must  be  treated  on  general  principles. 

1  Gunn,  Oph.  Hosp.  Reports,  x.  161. 


DISEASES     OF     THE     RETINA.  223 

There  are  cases  in  which  great  difficulty  is  experienced 
in  distinguishing  widely  diffused  and  superficial  choroiditis, 
with  pigmentation  of  retina  and  atrophy  of  the  disk,  from 
true  retinitis  pigmentosa.  The  question  will  generally 
relate  to  cause,  as  between  retinitis  pigmentosa  and  cho- 
roido-retinitis  from  syphilis  (p.  197).  But  other  cases  of 
choroido-retinal  disease  occur,  which,  though  easily  dis- 
tinguishable from  retinitis  pigmentosa,  are,  like  it,  related 
to  some  general  disease  of  the  nervous  system  in  the  patient 
or  his  parents,  and  not  to  syphilis. 


224  DISEASES    OF    THE    OPTIC    NERVE. 


CHAPTER  XV. 

DISEASES    OF    THE    OPTIC    NERVE. 

THE  optic  nerve  is  often  diseased  in  its  whole  length,  or 
in  some  part  of  its  course,  either  within  the  skull,  in  the 
orbit,  or  at  its  intraocular  end. 

The  effect  of  disease  of  the  optic  nerve  in  producing  (1) 
ophthalmoscopic  changes  in  its  visible  portion  (the  optic 
disk,  or  papilla  optica),  and  (2)  defect  of  sight,  varies 
greatly  according  to  the  seat,  nature,  and  duration  of  the 
disease.  The  appearance  of  the  disk  may  be  entirely 
altered  by  oadema  and  inflammation,  without  the  nerve- 
fibres  losing  their  conductivity,  and,  therefore,  without 
loss  or  even  defect  of  sight ;  on  the  other  hand,  inflamma- 
tory or  atrophic  changes,  causing  destruction  of  the  nerve- 
fibres,  may  arise  in  the  nerve  at  a  distance  from  the  eye, 
and,  whilst  producing  great  defect  of  sight,  cause  little  or 
no  immediate  change  at  the  disk.  Although  we  are  here 
concerned  chiefly  with  the  ophthalmoscopic  and  visual 
sides  of  the  question,  a  few  words  are  needed  as  to  the 
morbid  changes  in  the  nerve. 

The  pathological  changes  to  which  the  optic  nerve 
is  liable  include  those  which  affect  other  nerve-tissues. 
Inflammation  varying  in  seat,  cause,  and  rapidity,  and 
resulting  in  recovery  or  atrophy,  may  originate  in  the 
nerve  itself,  may  pass  down  it  from  the  brain  (descending 
neuritis),  or  may  extend  into  it  from  parts  around  ;  atrophy 
may  occur  from  pressure  by  tumors,  or  by  distention  of 
neighboring  cavities  (e.  g.,  the  third  ventricle),  or  from 
laceration  or  compression  after  fracture  of  the  optic  canal ; 


DISEASES    OF     THE     OPTIC     NERVE.  225 

and  the  optic  nerve  is  very  subject  to  the  change  known  as 
"  gray  degeneration  "  or  "  sclerosis." 

Lastly,  the  optic  nerve  being  surrounded  by  a  lymphatic 
space  ("  subvaginal  space  "),  which  is  continuous  through 
the  optic  foramen  with  the  meningeal  spaces  in  the  skull, 
and  is  bounded  by  the  tough  fibrous  "  outer  sheath"  of  the 
nerve,  is  liable  to  be  affected  by  fluid  or  inflammatory 
products  in  that  space.  Such  retention  or  secretion  of 
fluid  in  the  subvaginal  space  is  often  found  post  mortem,  in 
cases  of  the  optic  neuritis  about  to  be  described  as  so 
commonly  associated  with  intracranial  disease,  and  has 
been  held  to  explain  its  occurrence.  Recent  microscopical 
research,  however,  has  shown  that  in  many,  probably  in 
all,  cases  proofs  of  inflammation  can  be  traced  along  the 
whole  course  of  the  optic  nerves  from  their  intracranial 
part  to  the  eye.  The  occurrence  of  optic  papillitis1  in 
intracranial  disease  is  probably,  therefore,  explained  in  all 
cases  by  extension  of  inflammation  from  the  brain  or  its 
membranes  by  way  of  the  interstitial  connective  tissue,  or 
down  the  inner  nerve-sheath,  or  perhaps,  in  some  cases, 
along  the  intrinsic  bloodvessels  of  the  optic  nerve.  This 
explanation  by  "  descending  neuritis "  has  always  been 
accepted  for  the  papillitis  caused  by  meningitis.  But  other 
hypotheses,  which  have  been,  or  seem  likely  to  be,  given 
up,  have  hitherto  been  held  by  most  authorities  to  be  more 
applicable  to  the  papillitis  caused  by  cerebral  tumor, 
because  in  these  cases  the  signs  of  inflammation  in  the 
trunk  of  the  nerve  above  the  disk  are  often  slight,  and 
can  be  detected  only  by  a  careful  microscopical  ex- 
amination of  well-stained  sections.  The  part  taken  by 
the  fluid  which,  as  stated  above,  is  often  present  in  the 

1  Papillitis  has  been  proposed  by  Leber  to  designate  the  ophthal- 
moscopic  appearances  of  the  inflamed  or  swollen  disk,  without 
reference  to  theories  of  causation,  or  to  the  state  of  the  nerve 
trunk. 


226  DISEASES    OF     THE    OPTIC     NERVE. 

subvaginal  space  of  the  nerve  and  in  greatest  quantity 
close  to  the  eye,  is  not  yet  known.  It  may  possibly  act  in 
either  or  both  of  two  ways  ;  mechanically  by  compressing 
the  nerve  and  hindering  return  of  blood  from  the  retina, 
and  thus  complicating  an  already  existing  neuritis,  or 
vitally  by  carrying  inflammatory  germs  from  the  cranial 
cavity  to  the  optic  nerve.  It  is  not  yet  fully  known  how 
cerebral  tumors  set  up  descending  optic  neuritis  when  the 
absence  of  fluid  in  the  sheath  precludes  any  appeal  to  its 
influence ;  but  many  facts  point  to  the  probability  that  they 
do  so  by  lighting  up  irritation  with  increase  of  cell  growth 
in  the  surrounding  brain  substance,  or  in  other  cases  by 
causing  localized  meningitis.  Nor  is  it  fully  understood 
why  the  other  cranial  nerves  are  so  seldom  damaged,  at 
least  permanently.1 

As  already  stated  in  previous  chapters,  inflammation 
may  extend  into  the  disk  from  the  retina  or  choroid  near 
to  it,  and  may  occur  in  consequence  of  the  sudden  arrest 
of  the  blood-current  in  embolism  and  thrombosis  of  the 
central  retinal  vessels,  in  their  course  through  the  nerve. 

Ophthalmoscopic  signs  of  inflammation  of  the  optic  disk. 
— The  changes  caused  by  cedema  of  the  disk  are  mingled 
with  those  of  congestion  and  inflammation.  It  is  no  longer 
useful  to  maintain  the  old  distinction  between  "  swollen 
disk,"  or  "  choked  disk,"  attributed  to  compression  of  the 
optic  nerve  by  fluid  in  its  sheath,  or  with  less  reason 
to  pressure  upon  the  ophthalmic  vein  at  the  cavernous 
sinus,  and  "  optic  neuritis."  The  latter  term  was  formerly 
reserved  for  cases  showing  little  cedema,  but  much  opacity, 
changes  which  were  supposed  especially  to  indicate  in- 
flammation passing  down  the  trunk  of  the  nerve  from 

1  For  a  full  and  masterly  statement  of  this  difficult  subject, 
enriched  with  many  new  facts,  the  reader  is  referred  to  Dr. 
Gowers'  Manual  and  Atlas  of  Medical  Ophthalmoscopy  (p.  63). 


DISEASES     OF     THE     OPTIC     NERVE. 

the  brain.  The  changes  are  often  mixed  or  present  at 
different  stages  of  the  same  case.  The  terms  "  neuritis  " 
and  "papillitis 'n  will  be  here  used  to  the  exclusion  of 
"choked  disk." 

The  most  important  early  changes  in  optic  papillitis  are 
blurring  of  the  border  of  the  disk  by  a  grayish  opalescent 
haze,  distention  of  the  large  retinal  veins,  and  swelling  of 
the  disk  above  the  surrounding  retina.  Swelling  is  shown 


Ophthalmoscopic  appearance  of  severe  papillitis.  Several  elongated 
patches  of  blood  near  border  of  disk.  (After  Hughlings  Jackson.) 
Compare  with  Fig.  76. 

by  the  abrupt  bending  of  the  vessels,  with  deepening  of 
their  color  and  loss  of  the  light  streak — they  are,  in  fact, 
seen  foreshortened;  also  by  noticing  that  slight  lateral 
movements  of  the  observer's  head  or  lens  cause  an  apparent 

1  Much  light  has  within  the  last  two  or  three  years  been  thrown 
on  the  subject  by  the  microscopical  work  of  Gowers,  Stephen 
Mackenzie,  Edmunds,  and  Brailey,  in  this  country.  Trans,  of 
the  Ophthalmological  Society,  vol.  i.,  1881,  and  Trans,  of  the 
Internal.  Med.  Congress,  1881,  vol.  3,  p.  61. 


DISEASES    OF     THE     OPTIC     NERVE. 


movement  of  the  vessels  at  the  disk  over  the  choroid  behind, 
because  the  two  objects  are  on  different  levels  (j>.  213,  foot- 
note^. The  patient  may  die  or  the  disease  may,  after  n 
very  varying  time,  recede  at  this  stage.  But  generally, 
further  changes  occur;  the  haziness  becomes  decided 
opacity,  which  more  or  less  obscures  the  central  vessels 
and  covers  and  extends  beyond  the  border  of  the  papilla 
F_  "  -  :hat  the  disk  appears  considerably  increased 
in  diameter ;  its  color  becomes  a  mixture  of  yellow  and 
pink  with  gray  or  white,  and  it  looks  striated  or  fibrous, 
appearances  due  to  a  whitish  opacity  of  the  nerve-fibres 
mingled  with  numerous  small  bloodvessels  and  hemor- 
rhages. The  veins  become  larger  and  more  tortuous,  even 
kinked  or  knuckled;  the  arteries  are  either  normal  or 


Section  of  the  swollen  disk  in  papfflitis,  showing  that  the  swelling  is 
limited  to  the  layer  of  nerve-fibres  (longitudinal  shading) :  other  retinal 
layers  not  altered  in  thickness.  (Compare  with  Fig.  34.)  X  about  lo. 

somewhat  contracted  ;  there  may  be  blood  patches.  The 
swelling  of  the  disk  may  attain  a  very  high  degree,  the 
prominence  being  realized  chiefly  by  attention  to  the 
above-mentioned  changes  in  the  course  and  appearance  of 
the  vessels. 

Such  changes  may  disappear,  leaving  scarcely  a  trace; 


DISEASES    OF     THE     OPTIC     NERVE. 


229 


or  a  certain  degree  of  atrophic  paleness  of  the  disk,  with 
some  narrowing  of  the  retinal  vessels  and  thickening  of 
their  sheaths,  or  other  slight  changes,  may  remain.  But 
in  many  cases  the  disk  gradually,  in  the  course  of  weeks 
or  months,  passes  into  a  state  of  atrophy;  the  opacity  first 
becomes  whiter  and  smoother  looking  ("woolly  disk";; 
then  it  slowly  clears  off,  generally  first  at  the  side  next  the 
yellow  spot,  and  the  retinal  vessels  simultaneously  shrink 
to  a  smaller  size,  though  they  often  remain  tortuous  f  r  a 
long  time  (Fig.  77).  As  the  mist  lifts,  the  sharp  edge,  and 

PIG.  77. 


Atrophy  of  disk  after  papillitis. 

finally  the  whole  surface  of  the  disk,  now  of  a  staring-white 
color,  again  comes  into  view.  A  slight  haziness  often  re- 
mains, and  the  boundary  of  the  disk  is  often  notched  and 
irregular;  but  these  are  not  signs  upon  which  too  much 
reliance  must  be  placed.  The  degree  to  which  the  central 
vessels  are  shrunken  is  one  of  the  best  signs  of  the  degree 
of  atrophy  of  the  nerve  after  neuritis  ("consecutive"  or 
"post-papillitic"  atrophy). 

Sight  is  seldom  much  affected  until  marked  papillitis  has 
existed  some  little  time ;  if  the  morbid  process  quickly 
cease  no  failure  may  take  place,  or  sight  may  fail,  may 
even  sink  almost  to  blindness,  for  a  short  time,  and  recovery 

20 


230  DISEASES    OF    THE     OPTIC     NERVE. 

take  place  if  the  changes  cease  before  compression  of  the 
nerve-fibres  has  given  rise  to  atrophy.  Gradual  failure 
late  in  the  case,  when  retrogressive  changes  are  already 
visible  at  the  disk,  is  a  bad  sign.  The  sight  seldom  changes, 
either  for  better  or  worse,  after  the  signs  of  active  papillitis 
have  quite  passed  off,  and  though  the  relations  between 
sight  and  final  ophthalmoscopic  appearances  vary,  it  is 
usually  true  (1)  that  great  shrinking  of  the  principal 
retinal  vessels  indicates  great  defect  of  sight,  and  generally 
accompanies  extreme  pallor  with  some  permanent  residual 
haziness  of  the  disk  (advanced  post-papillitic  atrophy) ; 
(2)  that  considerable  pallor,  and  other  slight  changes,  sucli 
as  white  lines  bounding  the  vessels,  or  streaks  caused  by 
increase  of  the  connective  tissue  of  the  disk,  are  compatible 
with  fairly  good  sight,  if  the  central  vessels  are  not  much 
shrunken. 

Advanced  atrophy,  undoubtedly  following  papillitis,  does 
not,  however,-  always  show  signs  of  the  past  violent  inflam- 
mation; the  appearances  may  indeed  be  indistinguishable 
from  those  caused  by  primary  atrophy. 

Papillitis  is  double  in  the  great  majority  of  cases;  if 
single,  it  generally  indicates  disease  in  the  orbit.  In  the 
double  cases,  however,  there  are  often  inequalities,  in  time, 
degree,  and  final  result,  between  the  two  eyes.1 

The  changes  are  not  always  limited  strictly  to  the  disk 
and  its  border  (pure  papillitis),  for  in  some  cases  a  wide 
zone  of  surrounding  retina  is  hazy  and  swollen,  exhibiting 
hemorrhages  and  white  plaques,  or  lustrous  white  dots 
(papillo-retinitis,  neuro-retinitis).  It  is  not  always  easy  to 
say  in  such  a  case  whether  the  changes  are  due  to  renal 
disease  with  great  swelling  of  the  disk  (p.  216),  or  to  some 
intracranial  malady.  In  renal  cases  there  is  always  albu- 

1  Single  neuritis  has  been  seen  in  a  few  cases  of  cerebral  tumor 
by  Hughlings  Jackson,  and  others. 


DISEASES     OF    THE    OPTIC     NERVE.          231 

minuria,  the  patient  is  seldom  a  young  child,  and  the  cases 
with  most  severe  neuro-retinitis  occur  in  an  advanced  stage 
of  kidney  disease;1  in  the  cases  of  neuro-retinitis  most 
closely  resembling  renal  cases  but  caused  by  cerebral  dis- 
ease, there  will  be  no  albumen,  and  the  changes  will  sel- 
dom closely  resemble  those  of  albuminuria  until  they  have 
existed  for  long  and  caused  very  great  defect  of  sight. 

ETIOLOGY. — Papillitis  occurs  chiefly  in  cases  of  irritative 
intracranial  disease,  viz.,  in  meningitis,  both  acute  and 
chronic,  and  in  intracranial  new  growths  of  all  kinds, 
whether  inflammatory  (syphilitic  gummata),  tubercular,  or 
neoplastic.  It  is  very  rare  in  cases  where  there  is  neither 
iuflammation  nor  tissue  growth,  as  in  cerebral  hemorrhage 
and  intracranial  aneurism.  Further,  it  must  be  stated 
that  no  constant  relationship  has  been  proved  between 
papillitis  and  the  seat,  extent,  or  duration  of  the  intracranial 
disease.  Papillitis  has  occasionally  been  found  without 
coarse  disease,  but  with  widely  diffused  minute  changes,  in 
the  brain. 

Thus,  the  occurrence  of  papillitis,  although  pointing  very 
strongly  to  organic  disease  within  the  skull,  and  especially 
to  intracranial  tumor,  is  not  of  itself  either  a  localizing 
or  a  differentiating  symptom.  Inflammation  about  the 
sphenoidal  fissure,  thrombosis  of  the  cavernous  sinus,  and 
tumors  and  inflammations  in  the  orbit,  are  occasional 
causes  of  papillitis  and  of  descending  neuritis,  which  is 
then  usually  one-sided,  and  often  accompanied  by  extreme 
oedema  and  venous  distention;  in  some  of  these  there  is 
protrusion  of  the  eye  and  affection  of  other  orbital  nerves, 
and  the  exact  seat  of  disease  may  be  very  obscure. 

In  a  few  cases  well-marked  double  papillitis  occurs  with- 
out other  symptoms  and  without  assignable  cause.  Other 
occasional  causes  of  double  papillitis,  with  or  without 

1  Gowers,  p.  187. 


232  DISEASES     OF    THE    OPTIC    NERVE. 

retinitis,  are  lead  poisoning,  the  various  exanthemata, 
sudden  suppression  of  menstruation,  simple  ansemia,  and, 
perhaps,  exposure  to  cold. 

Certain  cases  of  failure  of  sight,  often  in  only  one  eye, 
with  slight  neuritic  changes  at  the  disk,  followed  by  recov- 
ery or  by  atrophy,  are  probably  to  be  referred  to  neuritis 
behind  the  eye  (retro-bulbar  neuritis).  The  changes  are 
clinically  very  different  from  any  of  those  above  described 
(see  page  240,  3). 

Syphilitic  disease  within  the  skull  is  a  common  cause  of 
papillitis,  but  the  eye  changes  alone  furnish  no  clue  to  the 
cause,  nor  to  its  mode  of  action,  which  may  be :  (1)  by 
giving  rise  to  intracranial  gumrna  not  in  connection  with 
the  optic  nerves,  but  acting  as  any  other  tumor  acts  (see 
above);  (2)  by  direct  implication  of  the  chiasma  or  optic 
tracts  in  gummatous  inflammation ;  (3)  in  rare  cases  neu- 
ritis ending  in  atrophy  and  blindness  occurs,  in  secondary 
syphilis,  with  severe  head  symptoms  pointing  to  acute 
meningitis. 

The  condition  of  the  pupil  in  neuritic  affections  depends 
partly  on  the  state  of  sight  and  partly  on  the  rapidity  of 
its  failure.  As  a  rule,  in  ainaurosis  from  atrophy  of  the 
disks  after  papillitis,  the  pupils  are  for  a  time  rather  widely 
dilated  and  motionless ;  after  a  while  they  often  become 
smaller,  and,  unless  the  blindness  be  complete,  they  regain 
a  certain  amount  of  mobility  to  light. 

ATROPHY  OF  THE  OPTIC  DISK. 

By  this  is  meant  atrophy  of  the  nerve-fibres  of  the  disk, 
and  of  the  capillary  vessels  which  feed  it.  It  is  shown  by 
change  of  color,  and  in  most  cases  by  a  preternatural 
sharpness  of  outline.  The  central  retinal  vessels  may  or 
may  not  be  shrunken.  The  disk  is  too  white  ;  milk-white, 
bluish,  grayish,  or  yellowish  in  different  cases.  Its  color 


DISEASES     OF     THE     OPTIC    NERVE.  233 

may  be  quite  uniform,  dead,  or  opaque  looking,  or  some  one 
part  may  be  whiter  than  another;  the  stippling  of  the 
lamina  cribrosa  (p.  69)  may  be  more  visible  than  in  health, 
or,  on  the  other  hand,  entirely  absent,  as  if  covered  or  filled 
up  by  white  pairt  (Figs.  78  and  79).  The  choroidal 

FIG.  78.  FIG.  79. 


Simple  atrophy  of  disk.     Stip-  Atrophy  of  disk  from  spinal  dis- 

pling  of  lamina  cribrosa  exposed.  ease.  Lamina  cribrosa  concealed. 
(Wecker.)  Vessels  normal.  (Wecker.) 

boundary  is  too  sharply  defined;  it  may  be  even  and 
circular,  or  irregular  and  notched.  Within  it  the  sclerotic 
ring  (p.  69)  is  often  seen  with  unnatural  clearness,  being 
even  whiter  than  the  nerve  which  it  encircles.  Mere  pallor 
of  the  disk,  as  is  present  in  extreme  general  anaemia,  must 
not  be  mistaken  for  atrophy ;  the  change  is  then  one  of 
color  only ;  there  is  neither  unnatural  distinctness,  loss  of 
transparency,  nor  disturbance  of  outline.  The  large  retinal 
vessels  are  to  be  carefully  noted  as  to  size  and  tortuosity, 
both  points  being  important  in  the  diagnosis  of  cause,  and 
for  prognosis. 

LOCAL  CAUSES. — (1)  The  nerve-fibres  undergo  atrophy 
during  the  absorption  and  shrinkage  of  the  new  connective 
tissue  formed  during  severe  neuritis,  whether  this  affect  the 
disk  alone  or  the  whole  length  of  the  nerve  (see  p.  230). 

20* 


234  DISEASES     OP     THE     OPTIC     NERVE. 

(2)  When  the  disk  participates  secondarily  in  inflam- 
mation of  the  retina  or  choroid  it  also  participates  in  the 
succeeding  atrophy  (pp.  197,  211). 

(3)  Atrophy  of  any  part  of  the  optic   nerve-trunk  or 
tract,  whether  from  pressure,  as  by  a  tumor,  or  by  disten- 
tion  of  the  third  ventricle  in  hydrocephalus,  from  injury, 
or   localized   inflammation,   leads  to   secondary  atrophy, 
which  sooner  or  later  becomes  evident  at  the  disk.     Such 
cases  often  show  the  conditions  of  pure  atrophy,  without 
complication  either  by  adventitious  opacity  or  disturbance 
of  outline,  and  often  without  change  in  the  retinal  vessels. 
They  are  not  very  common. 

(4)  The   optic  nerves   are   liable   to   chronic   sclerotic 
changes  with  thickening  of  the  connective-tissue   frame- 
work and  atrophy  of  the  nerve-fibres,  without  any  occurrence 
of  papillitis.     The  change  in  these  cases  appears  to  begin 
at  the  disk,  but  the  exact  order  of  events  is  not  fully  known 
in  this  large  and  important  group.     Groups  3  and  4  fur- 
nish the  cases  which  are  known  clinically  as  "  primary  "  or 
"progressive"  atrophy  of  the  optic  disk. 

Clinical  aspects  of  atrophy  of  the  disks. — As  in  optic 
neuritis,  so  in  atrophy  and  pallor  of  the  disk,  there  is  no 
invariable  relation  between  the  appearance  (especially  the 
color)  of  the  disk  and  the  patient's  sight.  A  considerable 
degree  of  pallor,  which  it  may  be  impossible  to  distinguish 
from  true  atrophy,  is  sometimes  seen  with  excellent  central 
vision  (p.  43),  though  usually  accompanied  by  some  defect 
of  the  visual  field.  -Again,  it  is  often  the  case  that  the  disks 
will  look  just  alike,  although  the  sight  is  much  better  in 
one  eye  than  in  the  other.  (Compare  Central  Amblyopia, 
p.  240,  4.) 

Patients  with  atrophy  of  the  disk  come  to  us  because 
they  cannot  see  well  or  are  completely  amaurotic.  There 
are  usually  no  other  local  symptoms  except  such  as  are 
furnished  by  the  pupils,  and  in  this  respect  cases  of  double 


DISEASES     OF     THE     OPTIC     NERVE.  235 

optic  atrophy  present  many  variations.  In  post-papillitic 
atrophy  the  pupils  are  generally  too  large,  and  sluggish  or 
motionless  to  light ;  in  most  cases  of  primary  progressive 
atrophy  they  are  of  ordinary  size,  or  smaller  than  usual, 
and  act  very  imperfectly.  When  only  one  eye  is  affected? 
the  other  being  quite  healthy,  the  pupil  of  the  amaurotic 
eye  has  no  direct  action  to  light  (p.  39)  and  it  may  be  a 
little  larger  than  its  fellow. 

The  visual  field,  in  cases  of  atrophy,  is  generally  con- 
tracted, or  shows  irregular  invasions  or  sector-like  defects. 
Color-blindness  is  a  marked  symptom  in  nearly  all  cases  of 
atrophy,  but  is  not  always  proportionate  to  the  loss  of 
vision,  being  in  some  much  greater  and  in  others  much  less 
than  the  state  of  vision  would  lead  us  to  expect  (see  also 
Amblyopia).  Green  is  the  color  lost  soonest  in  nearly  all 
cases,  and  red  next,  but  in  this  respect  variations  are  occa- 
sionally observed. 

A.  Cases  in  which  both  disks  are  atrophied  may  be  con- 
veniently classified  as  follows  in  regard  to  diagnosis  and 
prognosis. 

(1)  If  the   changes   point   decidedly  to   recently  past 
papillitis  (p.  229),  there  is  some  prospect  of  improvement; 
but,  on  the  other  hand,  sight  may  for  a  time  get  worse. 
The  case  must,  of  course,  be  investigated  most  carefully  as 
to  the  cause  of  the  neuritis.     If  sight  has  been  stationary 
for  some  months,  further  change  is  unlikely. 

(2)  Whenever  the  retinal  arteries  are  much  shrunken, 
whether  neuritis  have  occurred  or  not,  the  prognosis  is  bad 
(p.  230). 

(3)  The   most  careful  examination   leaves  it  uncertain 
whether  previous  papillitis  have  occurred.     Still,  as  con- 
secutive   cannot    always   be   distinguished   from   primary 
atrophy    (p.  230),   inquiry  should  be  made  for   previous 
symptoms  of  intracranial  disease.     But  in  a  large  number 
of  the  cases,  which  present  no  ophthalmoscopic  evidences 


236          DISEASES    OF     THE     OPTIC     NERVE. 

of  previous  papillitis,  the  history  will  be  quite  negative  as 
to  cerebral  symptoms ;  and  these  will,  for  the  most  part, 
fall  into  the  following  two  groups. 

(4)  There  are  symptoms  of  chronic  disease  of  the  spinal 
cord,  usually  of  locomotor  ataxy ;  or,  much  more  rarely, 
symptoms  of  general  paralysis. 

(5)  No  spinal  symptoms  can  be  made  out  and  no  cause 
assigned  for  the  atrophy;    these   are   relatively   common 
cases. 

The  sclerosis  leading  to  atrophy  of  the  disks  in  locomotor 
ataxy  (4)  usually  comes  on  early  in  that  disease,  often 
before  well-marked  spinal  symptoms  have  appeared.  The 
optic  atrophy  always  becomes  symmetrical,  though  it  gen- 
erally begins  some  months  sooner  in  one  eye  than  in.  the 
other;  it  always  progresses,  though  sometimes  not  for 
years,  to  complete,  or  all  but  complete  blindness.  The 
disks  are  usually  characterized  by  a  uniformly  opaque, 
gray-white  color,  the  lamina  cribrosa  being  often  concealed, 
although  neither  the  central  vessels  nor  the  disk  margin 
are  obscured  in  the  least  (Fig.  79).  The  central  vessels 
are  often  not  materially  lessened  in  size,  even  when  the 
patient  is  quite  blind. 

Numerous  cases  of  progressive  atrophy  are  seen  which 
agree  in  every  respect  with  the  above,  but  where  no  signs' 
of  spinal  cord  disease  are  present,  even  though  the  patient 
has  been  long  blind  (5).  It  is  known  that  in  some  of 
these  patients  ataxic  symptoms  come  on  sooner  or  later,  and 
it  is  highly  probable  that,  could  the  cases  be  followed  up 
for  a  sufficient  number  of  years,  this  result  would  be  found 
to  be  common.  Indeed,  preataxic  optic  atrophy  is  now 
a  recognized  method  of  onset  of  the  disease,  though  our 
information  is  incomplete,  and  we  do  not  yet  know  in 
what  proportion  of  cases  of  optic  atrophy  the  eye  disease 
remains  uncomplicated.  Cases  of  this  class  (5)  are  far 
commoner  in  men  than  in  women. 


DISEASES     OF     THE    OPTIC     NERVE.  237 

In  making  the  prognosis  of  cases  of  progressive,  uncom- 
plicated amblyopia  or  amaurosis,  with  more  or  less  atrophy 
of  disks,  special  attention  is  to  be  paid  to  whether  or  not 
the  failure  is  synchronous,  and  whether  it  is  now  equal  in 
the  two  eyes.  The  state  of  the  field  of  vision  in  cases  seen 
early  is  also  of  much  importance,  though  more  difficult  to 
make  out ;  peripheral  contraction,  as  distinguished  from 
central  defect,  is  a  bad  sign,  for  progressive  atrophy  sel- 
dom begins  with  defect  in  the  centre  of  the  field.  Cases 
of  gradual  uncomplicated  failure  of  sight,  in  which  the 
symptoms  have,  from  the  beginning,  been  equally  sym- 
metrical, will  generally  be  found  to  show  but  slight 
atrophic  changes  in  proportion  to  the  defect  of  sight, 
(Amblyopia,  p.  240,  4.) 

B.  Single  amaurosis  with  atrophy  of  the  disk,  in  a  ma- 
jority of  cases,  indicates  former  embolism  of  the  central 
artery  (p.  218),  or  some  local  affection  of  the  trunk  of 
the  optic  nerve  (pp.  231,  234,  240).  The  latter  cases  often 
give  a  history  of  having  suffered  from  severe  localized 
headache  or  neuralgia.  But  here  it  must  be  remembered 
that  in  cases  of  progressive  atrophy,  accompanying  or  pre- 
ceding spinal  disease,  a  very  long  interval  occasionally 
separates  the  onset  of  the  disease  in  the  two  eyes,  and  we 
may  see  the  first  eye  before  the  commencement  of  disease 
in  the  second. 

Single  amaurosis  following  immediately  after  injury  to 
the  head,  and  leading  in  a  few  weeks  to  atrophy,  indicates 
damage  to  the  nerve  from  fracture  of  the  optic  canal 
(p.  234,  3).  The  blow  is  generally  on  the  front  of  the 
head  and  on  the  same  side  as  the  affected  eye. 


238  AMBLYOPIA. 


CHAPTER    XVI. 

AMBLYOPTA    AND    FUNCTIONAL   DISORDERS    OF   SIGHT. 

THE  term  amblyopia  means  dulness  of  sight,  but  its  use 
is  generally  restricted  to  cases  of  defective  acuteness  of 
sight  (p.  43),  short  of  blindness,  in  which  the  visible 
changes  are  disproportionately  slight.  Amaurosis  indi- 
cates a  more  advanced  affection — complete  blindness  with- 
ont  apparent  cause.  These  terms  are  essentially  clinical, 
whilst  papillitis  and  atrophy  imply  easily  recognized  patho- 
logical changes  in  the  disk.  Amblyopia  may  depend 
upon  disease  in  the  retina,  in  any  part  of  the  optic  nerve 
or  tract,  or  in  the  optic  centres ;  and  it  may  be  temporary 
or  permanent.  It  is  always  most  important  to  distinguish 
single  from  symmetrical  cases. 

Two  common  and  important  forms  of  unsymmetrical 
amblyopia  may  be  considered  first. 

(1)  Amblyopia  from  suppression  of  the  image  in  one 
eye,  in  cases  of  squint.  A  squinting  person,  in  order  to 
avoid  the  difficulties  of  double  vision  (p.  33),  suppresses  the 
consciousness  of  the  image  formed  in  the  squinting  eye.  If 
this  process  be  continued,  the  sensorium  becomes  perma- 
nently blunted  for  images  in  this  eye ;  we  say  that  the  eye 
is  amblyopic  when  we  ought  to  say  that  the  corresponding 
centre  loses  perception.  This  defect,  though  often  very 
great,  affects  only  that  part  of  the  visual  field  which  is 
common  to  both  eyes,  and  is  therefore  least  marked  in  the 
outer  part  of  the  field.  It  continues  after  the  squint  has 
disappeared,  i.  e.,  when  both  eyes  are  again  directed  con- 
stantly to  the  same  object ;  but  it  can  be  relieved  or  cured, 


AMBLYOPIA.  239 

except  iu  very  bad  cases,  by  oft-repeated  "separate  practice 
of  the  defective  eye,  the  sound  eye  being  closed.  The  sup- 
pression is  much  more  easily  effected  by  some  persons  than 
others,  and  early  in  life  than  later ;  hence  those  who  have 
squinted  constantly  since  early  childhood  seldom  have  di- 
plopia  when  they  come  for  advice  several  years  after- 
wards, while  if  squint  be  acquired  later,  diplopia  lasts  for 
years  if  not  for  life.  When  the  suppression  is  temporary, 
even  though  often  repeated,  as  in  cases  of  alternating  and 
of  periodic  squint,  no  amblyopia  results.1 

(2)  Amblyopia  from  defective  retinal  images. — In  cases 
of  high  hypermetropia  or  astigmatism,  when  clear  images 
have  never  been  formed,  the  correction  of  the  optical  de- 
fect by  glasses  at  the  earliest  practicable  age  often  fails, 
at  any  rate  for  a  time,  to  give  full  acuteness  of  sight. 
Want  of  education  in  the  appreciation  of  clear  images  is 
probably  the  chief  cause,  though  defective  development 
of  the  retina  may  also  come  into  play.  We  may  explain 
in  the  same  way  the  common  cases  in  which,  with  ani- 
sometropia,  the  sight  of  the  more  ametropic  (p.  286)  eye, 
even  when  corrected  by  the  proper  glasses,  remains  de- 
fective, although  no  squint  have  existed;  and  in  some 
degree  also  the  defect  often  observed  after  perfectly  success- 
ful operations  for  cataract  in  children.  When  discovered 
late  in  life  this  defect  is  seldom  altered  by  correcting  the 
optical  error,  but  in  children  the  sight  may  improve  when 
the  suitable  glasses  are  constantly  worn. 

In  cases  of  amblyopia  not  belonging  to  either  of  these 
categories  a  definite  date  of  onset  will  generally  be  given. 

1  It  should  be  stated  that. this,  the  commonly  received,  explana- 
tion of  the  amblyopia  of  the  eyes  which  have  squinted  from  early 
life  has  been  assumed  on  the  theory  of  congenital  (rather  than 
acquired)  "correspondence"  between  the  two  retinae,  and  that 
it  is  doubted  by  so  high  an  authority  as  Prof.  Schweigger,  of 
Berlin. 


240  AMBLYOTIA. 

Two  principal  divisions  may  be  formed,  according  as  the 
defect  is  single  or  double.  It  must  here  be  noted,  how- 
ever, that  defect  or  blindness  of  one  eye  often  exists  un- 
known for  years,  until  accidentally  discovered  by  closing 
the  sound  eye.  This  ignorance  of  the  defect  is  most  com- 
mon when  the  failure  has  been  gradual,  painless,  and  not 
accompanied  by  any  change  in  the  appearance  of  the  eye. 
The  patient  is  naturally  alarmed  at  the  discovery ;  but 
much  caution  must  be  used  in  accepting  his  belief  that 
the  defective  eye  failed  when  its  defect  was  found  out. 
Sudden  failure  of  one  eye  is,  as  a  rule,  dated  correctly ; 
and  the  same  is  true  of  gradual  failure  of  the  right  eye 
in  a  man  used  to  rifle  shooting,  or  to  "sighting"  for  any 
purpose. 

(3)  Cases  of  recent  failure  of  one  eye  with  little  or  no 
ophthalmoscopic  change  occur   but  rarely,  generally   in 
young  adults;  the  onset  is   often   rapid,  with  neuralgic 
pains,  sometimes  very  severe,  in  the  same  side  of  the  head. 
There  may  be  pain  in  moving  the  eye,  or  tenderness  when 
it  is  pressed  back  into  the  orbit.    The  degree  of  amblyopia 
varies  much,  but  is  often  especially  marked  at  the  centre 
of  the  field.     The  disk  of  the  affected  eye  is  sometimes  hazy 
and  congested.     The  attack  is  often  attributed  to  exposure 
to  cold.     Most  of  the  cases  recover  under  the  use  of  blisters 
and  iodide  of  potassium,  but  in  a  certain  number  the  defect 
is  permanent,  and  the  disk  becomes  atrophied.     A  retro- 
bulbar  neuritis,  often  slight  and  transient,  most  likely  occurs 
(p.  232),  and  the  cases  are  perhaps  analogous  to  peripheral 
paralysis  of  the  facial  nerve. 

(4)  Much  commoner  is  a  progressive  and  equal  failure 
in  both  eyes,  often  amounting  in  a  few  weeks  or  months  to 
great  defect  (14  or  20  Jaeger,  or  V.  from  %  to  y1^),  with 
no  other  local  symptoms  except  perhaps  a  little  frontal 
headache,  but  often  with  general  want  of  tone,  nervousness, 
and  loss  of  sleep  and  appetite.     Ophthalmoscopic  changes, 


AMBLYOPIA.  241 

never  pronounced,  may  be  quite  absent.  At  an  early 
period  the  disk  is  often  decidedly  congested,  and  slightly 
swollen  and  hazy,  but  these  changes  are  so  ill-marked  that 
competent  observers  may  give  different  accounts  of  the  same 
case.  Later  the  side  of  the  disk  next  the  y.  s.,  and  finally, 
in  bad  cases,  the  whole  papilla,  becomes  pale,  and  the 
diagnosis  of  incomplete  atrophy  is  given.  The  defect  of 
sight  is  described  as  a  "  mist,"  and  is  usually  most  trouble- 
some in  bright  light  and  for  distant  objects,  being  less 
apparent  early  in  the  morning  and  towards  evening.  The 
pupils  are  normal,  or  at  most  rather  sluggish  to  light.  The 
defect  of  V.  is  limited  to,  or  much  greater  at,  the  central 
part  of  the  field  (causing  a  central  seotoma),  and  occupies 
an  oval  patch  from  the  fixation  point  (corresponding  to  the 
yellow  spot)  outwards  to  the  blind  spot  (corresponding  to 
the  optic  disk),  on  which  area  the  perception  of  green  and 
red  is  also  defective  or  absent.  This  symptom  may  often 
be  detected  by  moving  a  red  or  green  spot  (from  5  to  15  mm. 
square)  from  the  fixation  point  in  different  directions,  the 
eye  steadily  fixing  the  upheld  finger  or  other  object;  the 
color  of  the  spot  will  be  seen  best  (if  at  all)  at  a  little 
distance  from  the  fixation  point  (compare  p.  250) ;  in 
many  cases  no  color  defect  is  apparent  if  the  patient  be 
tested  with  large  masses  of  color.  The  periphery  of  the 
field  being  good,  no  difficulty  is  experienced  by  the  patient 
in  going  about,  the  large  surrounding  objects  being  visible ; 
hence  the  patient's  manner  differs  "from  that  of  one  with 
progressive  atrophy,  Avho  finds  difficulty  in  walking  about, 
etc.,  because  his  visual  field  is  contracted  (p.  234). 

The  patients  are  almost  without  exception  males,  and 
at  or  beyond  middle  life.  With  very  rare  exceptions  they 
are  smokers,  and  have  smoked  for  many  years,  and  a  large 
number  are  also  intemperate  in  alcohol.  The  exceptions 
occur  chiefly  in  a  very  few  patients  in  whom  a  similar  kind 
of  amblyopia  is  hereditary,  is  liable  to  affect  the  female  as 

21 


242  AMBLYOPIA. 

well  as  the  male  members,  and  sometimes  comes  on  much 
earlier  in  life.  The  etiology  of  these  cases  is  obscure.  In 
some  few  of  them  there  is  no  evidence  of  heredity. 

In  the  common  cases  it  is  now  generally  agreed  that 
tobacco  has  a  large  share  in  the  causation,  and  in  the 
opinion  of  an  increasing  number  of  observers  it  is  the  sole 
excitant.  The  direct  influence  of  alcohol,  and  of  the 
various  causes  of  general  exhaustion,  such  as  anxiety, 
underfeeding,  and  general  dissipation,  is  still  to  some  ex- 
tent an  open  question.  My  own  opinion,  based  on  the 
examination  of  a  large  number  of  cases,  is  that  tobacco  is 
the  essential  agent,  and  that  the  disuse  or  diminished  use 
of  tobacco  is  the  one  essential  measure  of  treatment.  It 
is  important  to  remember  that  the  disease  may  come  on 
when  either  the  quantity  or  the  strength  of  the  tobacco  is 
increased,  or  when  the  health  fails  and  a  quantity  which 
was  formerly  well  borne  becomes  excessive*  Hence  cases 
of  central  amblyopia  may,  as  a  rule,  except  in  the  rare  form 
above  mentioned,  be  named  tobacco  amblyopia. 

The  prognosis  is  good  if  the  case  come  to  treatment 
early,  and  if  the  failure  have  been  comparatively  quick. 
In  such  cases  really  perfect  recovery  may  occur,  and  an 
improvement  so  striking  that  the  patient  considers  his 
recovery  perfect  is  the  rule.  In  the  more  chronic  cases,  or 
cases  where  already  the  wrhole  disk  is  pale,  a  moderate 
improvement,  or  even,  an  arrest  of  progress,  is  all  we  can 
expect.  If  smoking  be  persisted  in  no  improvement  takes 
place,  and  the  amblyopia  increases  up  to  a  certain  point, 
but  complete  blindness  very  seldom,  if  ever,  occurs.  In 
the  treatment,  disuse  of  tobacco  is  the  one  thing  essential. 
If  the  man  drinks  too  much  he  should,  of  course,  lessen  the 
amount.  It  is  usual  to  give  strychnia  subcutaneously  or 
by  mouth  for  a  considerable  period,  but  whether  any  med- 
icine acts  otherwise  than  by  improving  the  general  tone  is 
doubtful ;  subcutaneous  injections  of  strychnia,  carefully 


AMBLYOPIA.  243 

carried  out,  have  not  given  definite  results  in  my  own  cases. 
There  is  reason  to  believe  that  the  disease  depends  on  a 
chronic  inflammation  of  the  central  bundles  of  the  optic 
nerve  beginning  at  a  distance  from  the  eye. 

Hemianopsia  (usually  called  hemiopia)  denotes  loss  of 
half  the  field  of  vision.  When  unilocular  the  defect  is 
seldom  quite  regular,  and  generally  depends  upon  detach- 
ment of  the  retina  or  a  very  large  retinal  hemorrhage.  It 
is  usually  binocular,  and  then  indicates  disease  at  or  behind 
the  optic  chiasma.  In  the  great  majority  of  cases  the  R. 
or  L.  lateral  half  of  each  field  is  lost.  The  line  of  separa- 
tion between  the  blind  and  the  seeing  halves  of  each  field 
may  pass  vertically  straight  through  the  fixation  point,  but 
more  commonly  it  deviates  a  little,  so  as  to  leave  intact  a 
small  area  of  the  field  around  the  fixation  point,  so  that 
central  vision  is  not  impaired;  the  transition  from  the 
seeing  to  the  blind  half  may  be  quite  abrupt,  or  rather 
gradual.  Loss  of  the  R.  half  of  each  field,  meaning  loss 
of  function  of  the  L.  half  of  each  retina,  points  to  disease 
of  the  L.  optic  tract  somewhere  between  the  chiasma  and 
the. corpora  geniculata;1  but  it  is  believed  that  lateral 
hemiopia  may  also  be  caused  by  disease  of  the  occipital 
lobe  and  angular  gyrus  (Ferrier).  Loss  of  the  two  nasal 
or  two  temporal  halves  is  extremely  rare.  Even  when 
hemianopsia  has  lasted  for  years  the  optic  disks  seldom 
show  any  change.  When  lateral  hemianopsia  coexists 
with  hemiplegia,  the  loss  of  sight  is  on  the  paralyzed  side ; 
"the  patient  cannot  see  to  his  paralyzed  side"  (Hughliugs 
Jackson) ;  sometimes  only  a  quarter  of  each  field  is  lost, 
e.  g.,  I  have  seen  the  R.  lower  quarter  lost  with  partial 
paralysis  of  the  R.  leg. 

1  Because  the  L.  optic  tract  consists  of  fibres  which  supply  the 
L.  half  of  each  retina,  those  of  them  destined  for  the  R.  eye 
crossing  over  at  the  optic  commissure. 


244  AMBLYOPIA. 

Hysterical  amblyopia  and  amaurosis  take  various  forms, 
and  real  defect  is  sometimes  mixed  up  with  conscious 
feigning.  In  hysterical  hemiansesthesia  the  eye  on  the 
affected  side  is  sometimes  defective  or  quite  blind.  In 
other  cases  of  hysteria  both  eyes  are  defective,  but  one 
worse  than  the  other;  there  is  concentric  contraction  of 
the  visual  fields,  sometimes  with,  sometimes  without  color- 
blindness, a  varying  degree  of  defective  visual  acuteness, 
and  sight  is  often  disproportionately  bad  by  feeble  light 
(hence  the  term  "  anaesthesia  of  the  retina"  is  sometimes 
used).  There  may,  however,  be  in  addition  irritative 
symptoms — watering,  photophobia  and  spasm  of  accommo- 
dation— and  then  the  term  "hypersesthesia  retinae"  or 
"  oculi "  seems  more  appropriate.1  It  is  important  to  note 
that  in  hysterical  cases,  even  when  one  eye  is  quite  blind 
or  has  bare  perception  of  light,  the  reflex  action  of  the 
pupil,  direct  as  well  as  indirect  (p.  39),  is  fully  preserved. 
The  prognosis  is  nearly  always  good,  though  recovery  is 
sometimes  slow.  In  some  of  the  wTorst  cases  I  have  seen 
there  has  been  considerable  ametropia  (p.  286). 

True  hysterical  amblyopia  seems  allied,  from  the  oph- 
thalmic standpoint,  with  a  much  larger  and  more  important 
class,  best  epitomized  by  the  term  asthenopia,  in  which  pho- 
tophobia, irritability,  and  want  of  endurance,  of  the  ciliary 
muscle  (accommodative  asthenopia),  or  sometimes  of  the 
internal  recti  (muscular  asthenopia)  with  some  conjunctival 
congestion,  are  the  main  symptoms,  acuteness  of  sight 
being  usually  perfect,  and  the  refraction  nearly  or  quite 
normal.  Of  the  retinal,  conjunctival,  and  muscular  factors, 
any  one  maybe  more  marked  than  the  others,  and  it  would 
seem  that,  given  a  certain  state  of  the  nervous  system? 
which  may  be  described  as  impressionable  or  hyperassthetic, 

1  These  cases  correspond  to  the  kopiopia  hysterica  of  Forster. 


AMBLYOPIA.  245 

over-stimulation  of  any  one  is  liable  to  set  up  an  over-sen- 
sitive state  of  the  other  two. 

These  patients  often  complain  also  of  dazzling,  pain  at 
the  back  of  the  eyes,  and  headache,  or  neuralgia  in  the 
head.  All  the  symptoms  are  worse  after  the  day's  work 
and  sometimes  on  first  waking  in  the  morning,  and  they 
are  liable  to  vary  much  with  the  health.  Artificial  light 
always  aggravates  them,  because  it  is  often  flickering  and 
insufficient,  but  especially  because  it  is  hot.  The  symptoms 
often  last  for  months  or  years,  causing  great  discomfort  and 
serious  loss  of  time. 

CAUSATION. — The  patients  are  seldom  children  or  old 
people.  Most  are  women,  either  young  or  not  much  past 
middle  life,  often  very  excitable,  and  often  with  feeble  cir- 
culation. If  men,  they  are  emotional,  fussy,  and  often 
hypochoudriacal.  Some  local  cause  can  also  generally  be 
traced,  such  as  close  application  at  needle-work,  reading, 
writing,  or  drawing.  Sometimes  working  on  bright  colors, 
glittering  things,  or  over  the  fire  seems  specially  injurious. 
In  other  cases  the  condition  follows  an  attack  of  phlycte- 
nular  ophthalmia,  or  superficial  ulcers,  which  has  left  the 
fifth  nerve  permanently  unstable. 

TREATMENT. — The  refraction  and  the  state  of  the  in- 
ternal recti  should  always  be  carefully  tested,  and  any 
error  corrected  by  spectacles.  Plain  colored  glasses  are 
sometimes  useful.  But  glasses  will  not  cure  the  disease, 
and  we  must  be  on  our  guard  against  promising  too  much 
from  their  use.  The  patient  may  be  assured  that  there  is 
no  ground  for  alarm,  and  that  the  symptoms  will  probably 
pass  off  sooner  or  later.  He  should  be  discouraged  from 
thinking  about  his  eyes,  and  he  need  seldom  be  quite  idle. 
The  artificial  light  used  should  be  sufficient  and  steady 
(not  flickering),  and  should  be  shaded  to  prevent  the  heat 
and  light  from  striking  directly  on  the  eyes.  Bathing  the 
eyes  freely  with  cold  water  and  the  occasional  employment 

21* 


246        FUNCTIONAL     DISEASES     OF     RETINA. 

of  weak  astringent  lotions  are  useful,  whilst  cold  air  acts 
beneficially  on  some  cases.  The  eyes  are  often  much  better 
after  a  rest  of  a  day  or  two.  Out-door  exercise  and  only 
moderate  use  of  the  eyes  therefore  should  be  enjoined. 
General  measures  must  be  taken  according  to  the  indica- 
tions, especially  in  reference  to  any  ovarian,  uterine,  or 
digestive  troubles,  or  to  sexual  exhaustion  in  men. 

FUNCTIONAL  DISEASES  OF  THE  RETINA. 

Functional  night-blindness  (endemic  nyctalopia)  is 
caused  by  temporary  exhaustion  of  the  retinal  sensibility 
from  prolonged  exposure  to  diffused,  bright  light.  The 
circumstances  under  which  it  occurs  usually  imply  not 
only  great  exposure  to  light,  but  lowered  general  nutrition, 
and  possibly  some  particular  defect  in  diet  may  be  neces- 
sary for  its  production.  It  has  often  coexisted  with  scurvy. 
Sleeping  with  the  face  exposed  to  bright  moonlight  is  be- 
lieved to  aid  its  occurrence.  It  is  commonest  in  sailors 
after  long  tropical  voyages  under  bad  conditions,  and  in 
soldiers  after  long  marching  in  bright  sun.  In  some  coun- 
tries it  prevails  every  year  in  Lent  when  no  meat  is  eaten, 
and  again  in  harvest  time.  It  is  now  but  rarely  indigenous 
in  our  country,  but  scattered  cases  occur  usually  in  chil- 
dren,1 and  it  still  occasionally  prevails  in  large  schools. 

In  this  malady  two  little  dry  films,  consisting  of  fatty 
or  sebaceous  matter  and  epithelial  scales,  often  form  on  the 
conjunctiva  at  the  inner  and  outer  border  of  the  cornea. 
Their  meaning  is  not  understood,  but  they  are  sometimes 
absent  in  this  disease  and  present  in  other  conditions.  In 
functional  nyctalopia  there  are  no  ophthalmoscopic  changes. 
The  disease  is  soon  cured  by  protection  from  bright  light 

1  Snell  reports  numerous  cases  from  near  Sheffield.  Transac- 
tions of  the  Ophthalmological  Society,  vol.  i.,  1881. 


FUNCTIONAL     DISEASES     OF    RETINA.        247 

and  improvement  of  health.  That  the  affection  is  local  in 
the  eye  is  shown  by  the  fact  that  darkening  one  eye,  by 
means  of  a  bandage  during  the  daytime,  has  been  found 
to  restore  its  sight  enough  for  the  ensuing  night's  watch 
on  board  ship,  the  unprotected  eye  remaining  as  bad  as 
ever.  Snow-blindness  (or  ice-blindness)  is  essentially  the 
same  disease,  with  the  addition  of  congestion,  pain,  photo- 
phobia, and  sometimes  of  conjunctival  ecchymoses.  These 
peculiarities  probably  depend  in  some  measure  on  the  effect 
of  the  rarefied  atmosphere  in  which  the  mountaineering 
cases  occur  and  on  the  local  effect  of  the  reflected  heat 
upon  the  conjunctiva.  Snow-blindness  is  effectually  pre- 
vented by  wearing  smoke-colored  glasses. 

Hemeralopia  (day-blindness)  occurs  in  certain  cases  of 
congenital  amblyopia. 

Micropsia. — Patients  sometimes  complain  that  objects 
look  too  small.  When  not  due  to  insufficiency  of  accom- 
modative power  (excessive  effort,  p.  45),  it  is  generally  a 
symptom  of  disease  of  the  outer  layers  of  the  retina,  espe- 
cially in  the  central  region,  and  syphilitic  retinitis  is  the 
commonest  cause  (p.  213).  Both  micropsia  and  its  opposite, 
megalopsia,  are  sometimes  seen  in  hysterical  amblyopia. 

Muscae  volitantes  are  seen  in  the  form  of  small  dots, 
rings,  threads,  etc.,  moving  about  in  the  field  of  vision, 
though  never  actually  crossing  the  fixation  point,  and 
never  interfering  with  sight.  They  are  most  easily  seen 
against  the  sky,  or  a  bright  background  such  as  the  micro- 
scope field.  They  depend  upon  minute  changes  in  the 
vitreous,  which  are  present  in  nearly  all  eyes,  though  in 
much  greater  quantity  in  some  than  others.  They  vary, 
or  seem  to  vary,  greatly  with  the  health,  but  are  of  no  real 
importance.  They  are  most  abundant  and  troublesome  in 
myopic  eyes. 

Diplopia  is  considered  under  Paralysis  of  the  Ocular 
Muscles.  (See  also  pp.  33  and  1 76,  for  Uniocular  Diplopia.) 


248        FUNCTIONAL     DISEASES     OF    RETINA. 

For  Affections  of  Sight  in  Megrim  and  Heart  Disease, 
see  Chapter  XXIII. 

Malingering. — Patients  now  and  then  pretend  defect  or 
blindness  of  one  or  both  eyes,  or  exaggerate  an  existing 
defect,  or  sometimes  secretly  use  atropine  to  paralyze  the 
accommodation.  In  most  cases  the  imposture  is  evident 
from  other  circumstances,  but  sometimes  great  difficulty  is 
found  in  detecting  it.  Malingering  is  far  less  common 
here  than  in  countries  where  the  conscription  is  in  force. 

The  pretended  defect  is  usually  confined  to  one  eye.  If 
the  patient  be  in  reality  using  both  eyes,  a  prism  held 
before  one  (by  preference  the  "blind"  one)  will  produce 
double  vision  (p.  25).  The  stereoscope,  and  also  colored 
glasses,  may  be  made  very  useful.  Another  test,  when 
only  moderate  defect  is  asserted,  is  to  try  the  eye  with 
various  weak  glasses,  and  note  whether  the  replies  are 
consistent ;  very  probably  a  flat  glass  or  a  weak  concave 
may  be  said  to  "  improve "  or  "  magnify "  very  much. 
Again,  atropine  may  be  put  into  the  sound  eye,  and  when 
it  has  fully  acted  the  patient  be  asked  to  read  small  print 
with  both  eyes  ;  if  he  reads  easily  the  imposture  is  clear, 
for  he  must  be  reading  with  the  so-called  "blind"  eye.  If 
absolute  blindness  of  one  be  asserted,  the  state  of  the  pupil 
will  be  of  much  help  (unless  the  patient  have  used  atro- 
pine);  for  if  its  direct, reflex  action  be  good  (p.  .39),  the 
retina  and  nerve  cannot  be  very  defective  (but  see  Hyster- 
ical Amblyopia). 

Asserted  defect  of  both  eyes  is  more  difficult  to  expose, 
and,  indeed,  it  may  be  absolutely  impossible  to  convict  the 
patient  if  he  is  intelligent  and  has  had  access  to  means  of 
information.  The  state  of  the  pupils,  of  the  visual  fields, 
and  of  color  perception,  are  amongst  the  best  tests. 

Color-blindness  may  be  congenital  or  acquired.  When 
acquired  it  is  symptomatic  of  disease  of  the  optic  nerve. 
It  may  also  occur  in  hysterical  amblyopia. 


FUNCTIONAL     DISEASES     OF     RETINA.        249 

Congenital  color-blindness  is  not  often  found  unless 
looked  for.  According  to  recent  and  extended  researches 
in  various  countries,  a  proportion  varying  from  about  three 
to  five  per  cent,  of  the  males  are  color-blind  in  greater  or 
less  degree,  and  it  appears  to  be  more  common  in  the  lower 
than  in  the  upper  classes.  These  facts  show  the  importance 
of  carefully  testing  all  men  whose  employment  renders 
good  perception  of  color  indispensable,  such  as  railway 
signalmen  and  sailors.  Color-blindness  is  usually  partial, 
i.  e.,  for  only  one  color  or  one  pair  of  complementary 
colors,  but  is  occasionally  total.  The  commonest  form  is 
that  in  which  pure  green  is  confused  with  various  shades 
of  gray  and  of  red  (red-green-blindness) ;  blindness  for 
blue  and  yellow  is  very  rare.  The  blindness  may  be  in- 
complete, perception  of  red,  e.  g.,  being  merely  enfeebled, 
whilst  bright  red  and  green  are  still  recognized  ;  or  it  may 
be  complete  for  all  shades  and  tints  of  those  colors.  Con- 
genital color-blindness  is  very  often  hereditary,  but  nothing 
further  is  known  of  its  cause,  It  is  very  rare  in  women 
(0.2  per  cent.).  The  acutenesss  of  vision  (i.  e.,  perception 
of  form)  is  normal.  Both  eyes  are  affected.1 

The  detection  of  color-blindness,  either  congenital  or 
acquired,  is  easy,  if,  in  making  the  examination,  we  bear 
in  mind  the  two  points  already  referred  to  at  p.  46,  viz.: 
(1)  Many  persons  with  perfect  color  perception  have  a  very 
imperfect  knowledge  of  the  names  of  the  various  colors, 
and  appear  color-blind  if  asked  to  name  them  ;  (2)  The 
really  color-blind  often  do  not  know  it,  having  learnt  to 
compensate  for  their  defect  by  attention  to  differences  of 
shade  and  texture.  Thus  a  signalman  may  be  color-blind 
for  red  and  green,  and  yet  may,  as  a  rule,  correctly  distin- 
guish the  green  from  the  red  light,  because  one  appears  to 
him  "brighter  "  than  the  other.  The  quickest  and  best 
way  of  avoiding  these  sources  of  error  has  been  mentioned 

1  But  on  this  point  farther  research  is  needed. 


250       FUNCTIONAL    DISEASES    OF    RETINA. 

at  p.  45.  Certain  standard  colored  Avools  are  given  to  the 
patient  without  being  named,  and  he  is  asked  to  choose 
from  the  whole  mass  of  skeins  of  wool  all  that  appear  to 
him  of  nearly  the  same  color  and  shade  (no  two  being 
really  quite  alike).  If,  for  example,  he  cannot  distinguish 
green  from  red,  he  will  place  the  green  test-skein  side  by 
side  with  various  shades  of  gray  and  red.  Wilful  conceal- 
ment of  color-blindness  is  impossible  under  this  test  if  a 
sufficient  number  of  shades  be  used. 

As  it  is  necessary  to  detect  slight  as  well  as  high  degrees, 
the  first  or  preliminary  test  should  consist  of  very  pale 
colors,  and  a  pale  pure  green  is  to  be  taken  as  the  test.  For 
ascertaining  whether  the  defect  be  of  higher  degree  or  not, 
stronger  colors  are  then  used ;  a  bright  rose  color,  e.  g., 
may  be  confused  with  blue,  purple,  green,  or  gray  of  cor- 
responding depth,  and  a  scarlet  with  various  shades  and 
tints  of  brown  and  green. 

It  may  here  be  noted  that  the  visual  field  is  not  of  the 
same  size  for  all  colors,  green  and  red  having  the  smallest 
fields,  and  that  the  perception  of  all  colors  is,  like  percep- 
tion of  form  (p.  43),  sharpest  at  the  centre  of  the  field 
(Fig.  26).  With  diminished  illumination  some  colors  are 
less  easily  perceived  than  others,  red  being  the  first  to  dis- 
appear, and  blue  persisting  longest,  i.  e.,  being  perceived 
under  the  lowest  illumination  ;  but  in  dull  light  the  colors 
are  not  confused  as  in  true  color-blindness.  In  congenital 
color-blindness,  as  we  have  seen,  red-green-blindness  is  the 
commonest  form ;  and  in  cases  of  amblyopia  from  com- 
mencing atrophy  of  the  optic  nerve  green  and  red  are 
almost  always  the  first  colors  to  fail,  blue  remaining  last. 


DISEASES  OF  THE  VITREOUS.      251 


CHAPTER    XVII. 

•     DISEASES    OF    THE    VITREOUS. 

THE  vitreous  humor  is  nourished  by  the  vessels  of  the 
ciliary  body,  of  the  retina,  and  of  the  optic  disk,  and  is 
probably  influenced  by  the  state  of  the  choroid  also.  In 
many  cases  disease  of  the  vitreous  can  be  proved  during 
life  to  be  associated  with  (and  dependent  on)  disease  of  one 
or  other  of  the  structures  named. 

Thus,  in  connection  with  various  surrounding  morbid 
processes,  the  vitreous  may  be  the  seat  of  inflammation, 
acute  or  chronic,  general  or  local,  and  of  hemorrhage.  It 
may  also  degenerate,  especially  in  old  age,  its  cells  and 
solid  parts  undergoing  fatty  degeneration,  become  visible 
as  opacities,  whilst  its  general  bulk  becomes  too  fluid.  The 
only  change  which  we  can  directly  prove  in  the  vitreous 
during  life  is  loss  of  transparency  from  the  presence  of 
opacities  moving,  or  more  rarely  fixed,  in  it ;  but  from  the 
freedom  and  quickness  of  their  movements,  some  idea  may 
also  be  formed  of  the  consistence,  or  degree  of  fluidity,  of 
the  humor  itself. 

Opacities  in  the  vitreous  may  take  the  form  of  large 
dense  masses,  as  from  abundant  or  recent  bleeding,  or  of 
membranes  like  muslin,  crape,  "  bee's  wings "  of  wine, 
bauds,  knotted  strings,  or  isolated  dots ;  and  they  may  be 
either  recent,  or  the  remains  of  long  antecedent  exudations 
or  hemorrhages.  Again,  the  vitreous  may  become  more 
uniformly  misty,  owing  to  the  diffusion  of  numberless  dots 
("  dust-like "  opacities),  which  need  careful  focussing  by 
direct  examination  to  be  separately  seen. 


252      DISEASES  OF  THE  VITREOUS. 

Opacities  in  the  vitreous  are  usually  detected  with  great 
ease  by  direct  ophthalmoscopic  examination  at  from  10" 
to  18"  from  the  patient,  but  are  generally  situated  too  far 
forward  (i.  e.,  too  far  within  the  focus  of  the  lens-system) 
to  be  seen  clearly  at  a  very  short  distance  (pp.  73  and  64,  c). 
By  asking  the  patient  to  move  his  eye  sharply  and  fully 
from  side  to  side  and  up  and  down,  the  opacities  will  be 
seen  against  the  red  ground,  as  dark  figures  which  continue 
to  move  after  the  eye  has  come  to  rest ;  they  are  thus  at 
once  distinguished  from  opacities  in  the  cornea  or  lens,  or 
from  dimly  seen  spots  of  pigment  at  the  fundus,  which  move 
only  whilst  the  eye  moves.  The  opacities  in  the  vitreous 
move  just  as  solid  particles  and  films  move  in  a  bottle  after 
the  bottle  has  been  shaken,  and  the  quickness  and  freedom 
of  their  movement  in  the  one  case  as  in  the  other  depends 
very  much  on  the  thinness  or  the  viscidity  of  the  fluid. 
Whenever  opacities  in  the  vitreous  pass  across  the  field 
quickly  and  make  wide  movements,  we  may  be  sure  that 
the  humor  is  too  fluid ;  and  the  contrary  may  be  concluded 
when  they  move  very  lazily.  In  some  cases  only  one  or 
twro  opacities  may  be  present,  and  may  only  come  into 
view  now  and  then.  Moving  opacities  in  the  vitreous 
obscure  the  fundus  both  to  direct  and  indirect  ophthalmo- 
scopic examination,  in  proportion  to  their  size,  density,  and 
position ;  a  few  isolated  dots  scarcely  affect  the  brightness 
of  the  ophthalmoscopic  image. 

The  opacities  may  lie  quite  in  the  cortex  of  the  vitreous, 
and  be  so  attached  to  the  retina  or  disk  as  to  have  no  inde- 
pendent movement.  These  are  generally  single,  are  found 
lying  either  over  or  near  to  the  disk,  and  may  be  the  result 
either  of  inflammation  or  of  hemorrhage ;  they  are  often 
membranous,  more  rarely  globular,  and  not  perfectly 
opaque.  Such  an  opacity  should  be  suspected  when,  by 
indirect  ophthalmoscopic  examination,  a  localized  haze  or 
blurring  of  some  part  of  the  disk  or  its  neighborhood  is 


DISEASES  OF  THE  VITREOUS.       253 

seen.  It  must  be  searched  for  by  the  direct  method  with 
the  eye  at  rest ;  by  carefully  accommodating  for  the  partic- 
ular part  which  appeared  hazy,  the  opacity  will  come 
sharply  into  view,  the  observer  being  at  a  greater  or  less 
distance  according  to  its  depth ;  if  the  eye  be  hyperme- 
tropic  a  convex  correcting  lens  may  be  necessary,  and  if 
considerably  myopic  a  concave.  The  kind  of  refraction 
must  therefore  be  known  in  order  to  make  this  examination 
properly  (p.  73).  Densely  opaque  white  membranes  may 
also  form  over  the  disk  or  upon  the  retina,  the  nature  and 
situation  of  which  are  diagnosed  in  the  same  way. 

Diffused  haziness  of  the  vitreous  causes,  in  a  correspond- 
ing degree,  dimness  of  outline  and  darkening  of  all  the 
details  of  the  fundus,  which  look  as  if  they  were  seen 
through  a  thin  smoke.  The  disk,  in  particular,  appears 
red,  without  really  being  so.  Very  much  the  same  appear- 
ances may  be  due  to  diffused  haze  of  the  cornea  or  lens,  the 
presence  of  which  will,  of  course,  have  been  excluded  by 
focal  illumination.  There  are  cases,  however,  where  though 
plenty  of  light  reaches  and  returns  from  the  fundus,  no 
details  can  be  seen,  even  indistinctly,  by  the  most  careful 
examination.  Probably,  in  such  a  case,  the  light  is  scat- 
tered by  innumerable  little  particles,  each  of  which  is 
transparent,  so  that  though  very  little  light  is  absorbed,  it 
is  all  distorted  and  broken  up,  as  in  passing  through  ground 
glass,  or  white  fog,  or  a  partial  mixture  of  fluids  of  different 
densities,  such  as  glycerine  and  water.  This  appearance  is 
found  chiefly  in  syphilitic  choroido-retinitis,  in  which  dif- 
fuse infiltration  of  the  vitreous  with  cells  is  known  to  occur. 
It  is  not  always  easy,  nor  indeed  possible,  to  distinguish 
with  certainty  between  diffuse  haze  of  the  vitreous  and 
diffuse  haze  of  the  retina  (p.  207). 

Crystals  of  cholesterin  sometimes  form  in  a  fluid  vit- 
reous, and  are  seen  with  bright  illumination  as  minute 

22 


254       DISEASES  OF  THE  VITREOUS. 

dancing  golden  spangles  \vhen  the  eye  moves  about  (spar- 
kling synchysis).  They  proportionately  obscure  the  fuudus. 
Large  opacities  just  behind  the  lens  may  be  seen  by  focal 
light  in  their  natural  colors.  In  rare  cases  of  choroido- 
retinitis  minute  growths  consisting  chiefly  of  bloodvessels 
form  on  the  retina  and  project  into  the  vitreous  ;  they  are 
rather  curiosities  than  of  practical  importance. 

Parasites  (cysticercus)  occasionally  come  to  rest  in  the 
eye,  and  in  development  penetrate  into  the  vitreous ;  they 
are  rarely  seen  in  England,  but  are  commoner  on  the 
Continent.  Very  rarely  a  foreign  body  may  be  visible  in 
the  vitreous. 

The  following  are  the  conditions  in  which  disease  of  the 
vitreous  is  most  commonly  found : 

(1)  Myopia  of  high  degree  and  old  standing;  the  opaci- 
ties move  very  freely,  showing  fluidity  of  the  humor,  and 
are  sharply  defined.  They  are  often  the  result  of  former 
hemorrhage. 

,  (2)  After  severe  blows,  causing  rupture  of  the  choroid 
or  of  some  vessels  in  the  ciliary  body.  When  recent  and 
situated  near  the  back  of  the  lens,  the  blood  can  often  be 
seen  by  focal  light;  if  very  abundant,  it  so  darkens  the 
interior  of  the  eye  that  nothing  whatever  can  be  seen  with 
the  mirror. 

(3)  After   perforating   wounds.      The   opacity  will   be 
blood  if  the  case  be  quite  recent.     Lymph  or  pus  in  the 
vitreous  at  the  inner  surface  of  the  wound  gives  a  yellow 
or  greenish-yellow  color,  easily  seen  by  focal  light  or  even 
by  daylight  (p.  151). 

(4)  In  rare  cases  large  hemorrhages  into  the  vitreous 
occur  spontaneously  in  healthy  eyes,  and   in    connection 
with  hemorrhagic  retinitis   and   hemorrhagic   choroiditis. 
Relapses  often  occur,  and  detachment  of  retina  may  come 
on.     The  subjects  are  generally  young  adult  males  liable 
to  epistaxis,  constipation,  and  irregularity  of  circulation 


DISEASES  OF  THE  VITREOUS.      255 

(Eales) ;    gout   may  have   some   influence    (Hutchinsou). 
(See  pp.  201  and  217.) 

In  all  of  the  above  cases  detachment  of  the  retina  is 
likely  to  occur  sooner  or  later,  and  if  present  the  difficulty 
of  diagnosis  between  the  two  conditions  may  be  consider- 
able (p.  213). 

(5)  Syphilitic  choroiditis  and  retinitis.     There  is  often 
diffuse  haze,  in  addition  to  large  slowly  floating  opacities. 
The  change  here  is  due  to  inflammation,  and  the  opacities 
may  entirely  disappear  under  treatment  (pp.  206,  213). 

(6)  Some  cases  of  cyclitis  and  cyclo-iritis  (p.  149). 

(7)  In   the   early   stage   of   sympathetic    ophthalmitis. 
The  opacities  are  inflammatory. 

(8)  In  various  cases  of  old  disease  of  choroid,  usually 
in  old  persons  and  without  proof  of  syphilis.     No  doubt 
many  of  these  indicate  former  choroidal  hemorrhages. 

(9)  The  vitreous  is  believed  to  become  repeatedly  and 
quickly  hazy  in  the  active  stages  of  glaucoma.     The  point 
is  difficult  to  settle   clinically,  because   the   cornea   and 
aqueous  are  nearly  always,  and  the  lens  often,  hazy  at  the 
same  time,  and  the  opportunity  of  examining  specimens  of 
uncomplicated  recent  glaucoma  scarcely  ever  occurs. 


256  GLAUCOMA. 


CHAPTER   XVIII. 

GLAUCOMA. 

IN  this  peculiar  and  very  serious  disease,  the  pathogno- 
monic  objective  symptom  is  increased  tightness  of  the  eye- 
capsule  (sclerotic  and  cornea),  "increased  tension;"  all  the 
other  phenomena  peculiar  to  the  disease  depend  upon  this 
condition.  The  disease  is  much  commoner  after  middle 
life,  when  the  sclerotic  becomes  less  distensible,  than  before; 
and  it  is  commoner  in  hypermetropic  eyes,  where  the  scle- 
rotic is  too  thick,  than  in  myopic  eyes,  where  it  is  thinned 
by  elongation  of  the  globe. 

Glaucoma  may  be  primary,  coming  on  in  an  eye  appar- 
ently healthy,  or  the  subject  of  some  disease,  such  as  senile 
cataract,  which  has  no  influence  on  the  glaucoma.  It  may 
also  be  secondary,  caused  by  some  still  active  disease  of 
the  eye,  or  by  conditions  left  after  some  previous  disease, 
such  as  iritis.  It  is  always  important,  and  seldom  difficult, 
to  distinguish  between  primary  and  secondary  glaucoma. 

Glaucoma  differs  in  severity  and  rate  of  progress  from 
the  most  acute  to  the  most  chronic  and  insidious  form. 
But  in  every  form  it  is  always  a  progressive  disease,  and 
unless  checked  by  treatment  nearly  always  goes  on  to  per- 
manent blindness.  It  generally  attacks  both  eyes,  though 
not  simultaneously,  the  interval  varying  from  a  few  days 
to  several  years. 

It  is  customary  to  speak  of  primary  glaucoma  as  either 
acute,  subacute,  or  chronic;  and  this  division,  though 
arbitrary,  is  useful  in  practice.  But  we  must  remember 
that  many  intermediate  forms  are  found,  and  that  the  same 


GLAUCOMA.  257 

eye  may,  at  different  stages  in  its  history,  pass  through  each 
of  the  three  conditions.  It  may,  indeed,  be  here  observed 
that  acute  and  subacute  outbursts  are  generally  preceded 
by  a  so-called  "  premonitory  "  stage,  in  which  the  symptoms 
are  not  only  chronic  and  mild,  but  remittent ;  the  intervals 
of  remission  becoming  shorter  and  shorter,  till  at  length 
the  attacks  become  continuous,  and  the  glaucomatous  state 
is  fully  established.  Rapid  increase  of  presbyopia,  shown 
by  the  need  for  a  frequent  change  of  spectacles,  is  a  com- 
mon premonitory  sign,  though  often  overlooked. 

Chronic  glaucoma  sets  in  with  a  cloudiness  of  sight  or 
"fog"  which  is  liable  to  variations,  and  often  quite  clears 
off  for  days,  or  even  weeks  ("premonitory  stage").  But 
in  some  cases,  so  far  as  the  patient  knows,  the  failure  is 
steady,  with  no  variations  or  remissions,  from  first  to  last. 
During  the  attacks  of  "  fog  "  artificial  lights  are  seen  sur- 
rounded by  colored  rings  ("rainbows"  or  "halos"),  which 
are  to  be  distinguished  from  those  due  to  mucus  on  the 
cornea.  The  attacks  of  fog  are  often  noticed  only  after 
long  use  of  the  eyes,  as  in  the  evening,  the  sight  being 
much  better  in  the  early  part  of  the  day.  The  defect  of 
sight  is  to  be  distinguished  from  that  caused  by  incipient 
nuclear  cataract,  disease  of  the  optic  nerve,  syphilitic  reti- 
nitis,  or  attacks  of  megrim.  Even  when  the  sight  has 
become  permanently  cloudy,  complete  recovery  no  longer 
occurring  between  the  attacks,  variations  still  take  place 
and  form  a  marked  feature.  There  is  no  congestion  and 
often  no  pain. 

If  we  see  the  patient  during  one  of  the  brief  early  fits 
of  cloudy  sight,  or  after  the  fog  has  settled  down  perma- 
nently, the  following  changes  will  be  found.  A  greater  or 
less  defect  of  sight  in  only  one  eye,  or  unequal  in  the  two, 
and  not  remedied  by  glasses;  the  pupil  a  little  larger  and 
less  active  than  normal ;  the  anterior  chamber  may  be 
shallow,  and  there  is  usually  slight  dulness  of  the  front  of 

22* 


258  GLAUCOMA. 

the  eye  from  steaminess  of  the  cornea,  or  from  haze  of  the 
aqueous,  and  some  engorgement  of  the  large  vessels  which 
perforate  the  sclerotic  at  a  little  distance  from  the  cornea 
(Figs.  20  and  22);  the  tension  will  be  increased  (usually 
about  -j-1,  p.  30)  and  the  field  of  vision  may  be  contracted, 
especially  011  the  nasal  side.  The  optic  disk  will  be  found 
normal,  pale,  or  sometimes  congested,  in  early  cases ;  pale 
and  cupped  (p.  262)  at  a  later  stage.  The  cupping  usually 
occupies  the  whole  surface,  but  sometimes  takes  the  form 
of  a  central  depression,  indistinguishable  from  a  large 
steep-sided  physiological  cup  (p.  77).  There  may  be  spon- 
taneous pulsation  of  all  the  vessels  on  the  disk;  or  the 
arteries,  if  not  pulsating  spontaneously,  will  do  so  on  very 
slight  pressure  on  the  eyeball  (p.  72).  If  the  case  is  of  old 
standing,  the  tension  will  often  be  considerably  increased, 
the  pupil  dilated  though  still  active,  the  lens  often  hazy, 
the  field  of.  vision  greatly  contracted,  acuteness  of  vision 
extremely  defective,  the  cornea  sometimes  clear,  in  other 
cases  dull.  In  nearly  all  cases  of  glaucoma  the  temporal 
part  of  the  field  (nasal  part  of  the  retina)  retains  its  func- 
tion longest ;  and  in  advanced  cases  the  patient  will  often 
himself  say  or  show  that  he  sees  only  in  this  direction. 

An  eye  in  which  the  above  symptoms  have  set  in  may 
progress  to  total  blindness  in  the  course  of  months  or 
several  years  without  a  single  "inflammatory"  symptom, 
without  either  pain  or  redness — chronic  painless  glaucoma 
(glaucoma  simplex) ;  and  since  the  lens  often  becomes  parti- 
ally opaque,  and  of  a  grayish  or  greenish  hue,  cases  of 
chronic  glaucoma  are  sometimes  mistaken  for  senile  cata- 
ract. 

But  more  commonly,  in  the  course  of  a  chronic  case, 
periods  of  pain  and  congestion  occur,  with  more  rapid 
failure  of  sight;  or  the  disease  sets  in  with  "  inflammatory" 
symptoms  at  once.  Indeed,  the  commonest  cases  are  those 
of  subacute  glaucoma,  where,  besides  the  symptoms  named 


GLAUCOMA.  259 

above,  we  find  dusky  reticulated  congestion  of  the  small 
and  large  episcleral  vessels  in  the  ciliary  region  (Fig.  24), 
with  pain  referred  to  the  eye,  or  to  the  side  of  the  head,  or 
nose,  and  rapid  failure  of  sight.  The  increase  of  tension, 
steaminess,  and  some  anaesthesia  of  the  cornea,  dilatation 
and  sluggishness  of  pupil,  and  shallowing  of  the  anterior 
chamber,  are  all  more  marked  than  is  usual  in  chronic 
cases,  and  the  media  are  too  hazy  to  allow  a  good  ophthal- 
moscopic  examination. 

These  symptoms,  ending  after  a  few  weeks  or  months  in 
complete  blindness,  may  remain  at  about  the  same  height 
for  months  afterwards  with  slight  variations,  the  eye  gradu- 
ally settling  down  into  a  permanent  state  of  severe,  but 
chronic,  non-inflammatory  glaucomatous  tension.  In  other 
cases  a  subacute  attack  passes  off  only  to  return  in  greater 
severity  a  few  weeks  or  days  later  (remittent  glaucoma). 

Acute  glaucoma  differs  from  the  other  forms  only  in 
suddenness  of  onset,  rapidity  of  loss  of  sight,  and  severity 
of  congestion  and  pain.  The  congestion,  both  arterial  and 
venous,  is  intense ;  in  extreme  cases  the  lids  and  conjunctiva 
are  swollen,  and  there  is  photophobia,  so  that  the  case  may 
be  mistaken  for  an  acute  ophthalmia.  All  the  specific 
signs  of  glaucoma  are  intensified ;  the  pupil  considerably 
dilated  and  motionless  to  light,  the  cornea  very  steamy,  the 
anterior  chamber  very  shallow,  and  tension  -(-2  or  3.  Sight 
will  fall  in  a  day  or  two  down  to  the  power  of  only  count- 
ing fingers,  or  to  mere  perception  of  light,  and  if  the  case 
have  lasted  a  week  or  two  all  p.  1.  is  usually  abolished. 
The  pain  is  very  severe  in  the  eye,  temple,  back  of  the  head 
and  down  the  nose;  not  unfrequently  it  is  so  bad  as  to 
cause  vomiting,  and  the  case  is  often  mistaken,  even  by 
medical  men,  for  a  "  bilious  attack "  with  a  "  cold  in  the 
eye,"  for  "neuralgia  in  the  head,"  or  "rheumatic  oph- 
thalmia." Some  cases,  however,  though  very  acute,  are 
mild  and  remit  spontaneously ;  but  such  cases,  like  those 


260 


GLAUCOMA. 


mentioned  in  the  preceding  paragraph,  often  pass  on  into 
the  severe  type  just  described. 

Absolute  glaucoma  is  glaucoma  which  has  led  to  per- 
manent blindness.  Such  an  eye  continues  to  display  the 
tension  and  other  signs  of  the  disease,  and  remains  liable 
to  relapses  of  acute  symptoms  for  varying  periods,  but  in 
many  "  absolute  "  cases,  especially  those  which  follow  acute 
forms  of  glaucoma,  changes  occur  sooner  or  later,  leading 
to  staphylomata,  cataract,  atrophy  of  iris,  and  finally  to 
softening  and  shrinking  of  the  globe.  The  term  "glaucoma 
fulminans"  denotes  extremely  severe  acute  glaucoma, 
abolishing  sight  in  a  few  hours. 

As  a  rule,  glaucoma  runs  the  same  course  in  the  second 
eye  as  in  the  first,  but  sometimes  it  will  be  chronic  in  one 
and  acute  or  subacute  in  the  other. 

EXPLANATION  OF  THE  SYMPTOMS. — The  increase  of 
tension  lowers  the  functional  activity  of  the  retina  by  com- 

FIG.  80. 


Section  of  very  deep  glaucoma  cup.     (Compare  Fig.  34.) 

pressing  it,  and  also  by  impeding  the  flow  of  arterial  blood 
to  and  of  venous  blood  from  it.  When  the  retinal  vessels 
can  be  seen  in  glaucoma  the  arteries  are  somewhat  nar- 
rowed, and  often  exhibit  spontaneous  pulsation,  whilst  the 


GLAUCOMA.  261 

veins  are  always  somewhat  engorged.  This  want  of  blood 
must  first  affect  the  peripheral  parts,  because  the  blood  has 
to  overcome  more  resistance  in  reaching  them,  and  this 
probably  explains  the  contraction  of  the  visual  field.  The 
nutrition  of  the  inner  retinal  layers  suffers  if  the  pressure 
be  kept  up  (1)  from  the  insufficiency  of  arterial  blood,  and 
the  changes,  including  hemorrhage,  which  follow  impeded 
venous  outflow7;  (2)  from  stretching  and  atrophy  of  the 
nerve-fibres  on  the  disk.  The  floor  of  the  disk  (lamina 

FIG.  81. 


Ophthalmoscopic  appearance  of  slight  cupping  of  the  disk  in  glaucoma. 
(Wecker  and  Jaeger.)     X  7. 

cribrosa),  being  the  weakest  part  of  the  eye-capsule,  slowly 
yields  and  is  pressed  backwards,  the  nerve-fibres  being 
dragged  upon,  displaced,  and  finally  atrophied ;  the  direct 
pressure  on  the  nerve-fibres,  as  they  bend  over  the  edge  of 
the  disk,  also  helps  in  the  same  process.  Hence  finally 
the  disk  becomes  not  only  atrophied,  but  depressed  or 
hollowed  out  (Fig.  80).  This  hollow  is  the  well-known 
"glaucomatous  cup"  which,  when  deep,  has  an  overhang- 


GLAUCOMA. 


ing  edge,  because  the  border  of  the  disk  is  smaller  at  the 
level  of  the  choroid  than  at  the  level  of  the  lamina  cribrosa 
(Fig.  34) ;  its  sides  are  quite  steep  even  when  the  cup  is 
shallow  (Fig.  82). 

With  the  ophthalmoscope,  this  cupping  is  shown  by  a 
sudden  bending  of  the  vessels  just  within  the  border  of  the 
disk,  where  they  look  darker  because  foreshortened  (Fig. 
81)  ;  if  the  cup  be  deep,  they  may  disappear  beneath  its 
edge  to  reappear  on  its  floor,  where  they  have  a  lighter 
shade  (Fig.  83). 

The  vessels,  as  a  rule,  do  not  all  bend  with  equal  abrupt- 
ness, some  parts  of  the  disk  being  more  deeply  hollowed 
than  others,  or  some  of  the  vessels  spanning  over  the 

FIG.  82. 


Section  of  less  advanced  glaucoma  cup. 

interval  instead  of  hugging  the  wall  of  the  cup.  It  is 
probable  that  increase  of  tension  must  be  maintained  for 
several  months  to  produce  cupping  recognizable  by  the 
ophthalmoscope.  When  recent  acute  glaucoma  has  been 
cured  by  operation  the  disk  is  not  cupped;  often,  however, 
it  becomes  very  pale.  Although  in  many  cases  the  ex- 
cavation extends  from  the  first  over  the  whole  surface  of 
the  disk,  this  is  not  always  so ;  the  depression  starts,  in 
some  of  the  most  chronic  cases,  at  the  thinnest  part  (the 
physiological  pit),  and  enlarges  towards  the  periphery 


GLAUCOMA.  263 

(p.  258).  A  deep  cup  is  sometimes  partly  filled  up  by  fibrous 
tissue,  the  result  of  chronic  inflammation,  its  true  dimen- 
sions not  being  then  appreciable  by  the  ophthalmoscope. 

The  shallowness  of  the  anterior  chamber  is  probably 
due  to  advance  of  the  lens  ;  it  is  by  no  means  a  constant 
symptom.  The  pressure  on  the  ciliary  nerves  accounts 
for  the  somewhat  dilated  and  immovable  pupil  and  for  the 
corneal  anaesthesia.  In  old-standing  cases  the  iris  is  often 

FIG.  83. 


Ophthalmoscopic  appearance  of  deep  cupping  of  the  disk  in  glaucoma. 
(Altered  from  Liebreich.)     X  about  15. 

shrunken  to  a  narrow  rim  ;  in  uncomplicated  glaucoma 
iritic  adhesions  are  never  seen.  The  corneal  changes  de- 
pend partly  on  "  steaminess "  of  the  epithelium,  partly 
upon  haze  of  the  corneal  tissue  from  oedema  (Fuchs).  In 
recent  cases  the  aqueous  humor  is  somewhat  turbid.  The 
lens  appears  to  lose  some  transparency  even  in  fresh  cases, 
if  severe;  in  old  cases,  as  already  stated,  it  often  becomes 
slowly  opalescent,  and  finally  quite  opaque.  It  is  generally 
stated  that  the  vitreous  humor  becomes  hazy  during  the 
attacks,  especially  in  severe  cases,  but  since  it  is  just  in 
these  very  cases  that  the  cornea  and  aqueous  are  most  dull, 


264 


GLAUCOMA. 


the  statements  about  the  vitreous  are  conjectural  (p.  255). 
The  internal  pressure  tends,  in  acute  cases,  to  make  the 
globe  spherical,  by  reducing  the  curvature  of  the  cornea 
to  that  of  the  sclerotic;  it  also  in  all  cases  weakens  the 
accommodation,  at  first  by  pressing  on  the  ciliary  nerves, 
later  by  causing  atrophy  of  the  ciliary  muscle ;  these  facts 
together  explain  the  rapid  decrease  of  refractive  power 
(i.  e.,  rapid  onset  or  increase  of  presbyopia)  which  is  some- 
times noticed  by  the  patient  (p.  257).  The  choroidal  circu- 
lation is  obstructed  by  the  increase  of  pressure,  and  iff 
severe  glaucoma,  especially  of  old  standing,  the  anterior 
ciliary  veins  (forming  the  episcleral  plexus)  (Figs.  20  and 
24),  as  well  as  the  arteries,  become  very  much  enlarged. 

FIG.  84. 


Section  through  the  ciliary  region  in  a  healthy  human  eye.  Co., 
cornea;  Scl.,  sclerotic;  C.  M.,  ciliary  muscle ;  C.  P.,  two  ciliary  processes, 
one  larger  and  more  prominent  than  the  other;  Jr.,  iris;  L.,  marginal 
part  of  the  crystalline  lens;  a,  angle  of  anterior  chamber;  e?,  membrane 
of  Descemet,  which  ceases  (as  such)  before  reaching  the  angle  a.  The 
dotted  line  shows  the  course  taken  by  fluid  from  the  anterior  part  of  the 
vitreous  into  the  posterior  aqueous  chamber,  thence  through  the  pupil 
(not  shown)  into  the  anterior  aqueous  chamber,  to  the  angle  a.  Suspen- 
sory ligament  of  lens  not  shown.  X  10. 

MECHANISM  OF  GLAUCOMA. — The  increased  tension  is 
due  to  excess  of  fluid  in  the  eyeball.  Impeded  escape  is 
probably  the  chief  cause  of  this  excess,  and  recent  research 


GLAUCOMA. 


265 


has  proved  that  changes  are  present  in  nearly  all  glauco- 
matous  eyes,  which  must  lessen  or  prevent  the  normal 
outflow.  But  increased  secretion,  and  internal  vascular 
congestion,  of  the  eyeball  undoubtedly  play  an  important 
part  in  some  cases.  Both  conditions  would  have  most 
effect  when  the  sclerotic  was  most  unyielding,  i.  e.,  in  old 
age,  and  in  hypermetropic  eyes  (p.  256).  Normally  there 
is  a  constant  movement  of  fluid  from  the  vitreous  humor 
through  the  suspensory  ligament  of  the  lens  into  the 
anterior  chamber  in  the  course  shown  by  the  dotted  line 
in  Fig.  84.  The  fluid  escapes  from  the  anterior  chamber 
into  the  lymphatics,  and  perhaps  into  the  veins,  of  the 
sclerotic  through  the  meshed  tissue  of  the  ligamentum 
pectinatum,  which  closes  the  angle  a  ;  and  it  has  been 
proved  that  very  little  fluid  can  pass  through  any  other 


Ciliary  region  from  a  case  of  acute  glaucoma  of  one  month's  duration. 
(1  and  2,  situations  of  iridectomy  wounds  in  two  cases.)     X  10. 

part  of  the  cornea.  In  glaucoma  this  angle  is  nearly 
always  closed,  in  recent  cases  by  contact,  in  old  cases  by 
permanent  cohesion  between  the  periphery  of  the  iris  and 
the  cornea  (Figs.  85  and  86).  No  complete  explanation 
of  this  advance  of  the  iris  has  yet  been  given.  Dr.  Adolf 
Weber  holds  that  the  ciliary  processes  becoming  swollen 
from  various  causes  push  the  iris  forwards  and  so  start  the 

23 


266  GLAUCOMA. 

glaucomatous  state.  Priestly  Smith  believes  the  primary 
obstruction  to  depend  upon  narrowing,  or  even  oblitera- 
tion, of  the  circular  chink  ("  circumlental  space  ")  between 
the  edge  of  the  lens  and  the  tips  of  the  ciliary  processes, 
and  that  this  proceeds  mainly  from  a  progressive  increase 
in  the  size  of  the  lens  which  occurs  in  old  age  ;l  obstruction 

FIG.  86. 


Ciliary  region  in  chronic  glaucoma  of  three  years'  standing.     X  10. 

here  leads  to  rise  of  pressure  in  the  vitreous,  followed  by 
advance  of  the  lens  and  ciliary  processes,  pressure  on  the 
iris,  and  closure  of  the  angle ;  swelling  of  the  ciliary  pro- 
cesses would  be  a  contributory  cause.  Brailey  holds  that 
a  chronic  inflammation  of  the  ciliary  muscle  and  processes 
and  of  the  iris,  quickly  passing  on  to  atrophic  shrinking, 
leads  to  narrowing  of  the  angle  and  initial  rise  of  tension  ;2 
in  his  latest  paper,  however,  he  agrees  to  some  extent  with 
the  view  of  Weber  above  referred  to.3  Glaucoma  is  some- 
times caused  by  obstruction  at  the  pupil  (circular  synechia 
following  iritis,  p.  139).  It  may  be  caused  by  the  pressure 
of  a  swollen  (wounded)  lens  on  the  iris  and  ciliary  processes 
(p.  180).  It  also  often  occurs  in  the  course  of  sympathetic 

1  Priestly  Smith  on  Glaucoma,  1879 ;  Ophth.  Hosp.  Reports,  x. 
25,  1880;  Int.  Med.  Congress,  1881.  More  data  are  needed  before 
this  increase  in  the  size  of  the  lens  can  be  assumed  to  occur  as  the 
rule. 

*  Brailey,  Ophth.  Hosp.  Reports,  x.  pp.  14,  89,  93  (1880). 

8  Brailey,  ibid.,  p.  282  (1881). 


GLAUCOMA.  267 

ophthalmitis,  and  in  some  cases  of  irido-cyclitis  (pp.  149, 
154).  In  the  latter  it  is  due  to  choking  of  the  ligamentum 
pectinatum  by  inflammatory  materials,  not  to  obliteration 
of  the  angle. 

EFFECT  OF  OVER-SUPPLY  OF  FLUIDS  ON  THE  TENSION. 
— Functional  hypersemia  and  ordinary  inflammations  of 
the  retina  and  choroid  do  not  cause  glaucoma,  and  dilata- 
tion of  the  arteries  by  vaso-motor  paralysis  is  said  to  be 
accompanied  by  diminished  tension.  But  tumors  in,  and 
even  upon,  the  eye  often  give  rise  to  secondary  glaucoma, 
and  probably  an  important  factor  in  these  cases  is  the 
active  congestion  and  trausudation  which  occur  near 
quickly  growing  tumors ;  certainly  the  glaucoma  stands 
in  no  definite  relation  either  to  the  size  or  position  of  the 
tumor.  A  relation  is  observed  in  some  cases  between 
glaucoma  and  a  liability  to  neuralgia  of  the  fifth  nerve ; 
and  T.  is  said  to  be  lowered  in  paralysis  of  this  nerve. 
Probably  the  neuralgia  acts  indirectly  by  causing  associ- 
ated congestion,  and  thus  setting  up  glaucoma  in  an  eye 
predisposed  to  it. 

GENERAL  AND  DIATHETIC  CAUSES. — In  an  eye  predis- 
posed by  the  changes  above  mentioned  at  the  rim  of  the 
anterior  chamber,  any  cause  of  congestion  may  precipitate 
an  acute  attack.  Vascular  engorgement  of  the  eyes  in  con- 
nection with  digestive  disturbances,  gout,  or  neuralgia,  or 
the  same  result  brought  on  by  the  over-use  of  presbyopic 
eyes  without  suitable  glasses,  or  a  blow,  or  prolonged  oph- 
thalmoscopic  examination,  may  all  bring  it  about.  Atro- 
pine,  which  has  the  power  of  increasing  the  eye-tension, 
has  sometimes  caused  an  attack,  probably  because  by 
lessening  the  width  of  the  iris  it  increases  its  thickness, 
and  so  crowds  it  into  the  angle  of  the  anterior  chamber. 
Iridectomy  in  one  eye  occasionally  has  the  effect  of  pre- 
cipitating the  disease  in  the  other,  but  its  mode  of  action 
is  unexplained.  Glaucoma  is  commoner  in  women  than 


268  GLAUCOMA. 

in  men,  and  after  than  before  the  age  of  forty-five.  It  is 
very  rare  in  young  adults  and  children,  and  is  then  gen- 
erally chronic  and  often  gives  rise  to  or  is  associated  with 
other  changes  in  the  eyes.  Acute  cases  are  often  dated 
from  a  period  of  overwork  of  the  eyes,  or  of  want  of 
sleep,  as  from  sitting  up  nursing,  etc.  There  is  not  unfre- 
quently  a  history  of  gout.  Hence,  patients  who  have  had 
glaucoma  in  one  eye  should  be  strongly  warned  as  to  the 
danger  of  over-using  the  eyes  and  of  working  without 
proper  glasses,  and  against  dietetic  errors. 

TREATMENT. — Iridectomy  or  an  equivalent  operation 
is,  with  very  few  exceptions,  the  only  curative  treatment. 
Eserine  (the  alkaloid  of  Calabar  bean)  used  locally,  how- 
ever, diminishes  the  tension  in  acute  glaucoma,  and  some 
few  attacks  have  been  permanently  cured  by  its  means 
alone.  But  although  really  curative  in  only  a  few  cases, 
eserine  is  valuable  for  temporary  use  in  cases  where  an 
operation  cannot  be  immediately  performed.  It  has  little 
or  no  effect  on  the  tension  unless  marked  contraction  of 
the  pupil  follows  its  use.  Eserine  probably  acts  by  stretch- 
ing the  iris  and  drawing  it  away  from  the  angle  of  the 
anterior  chamber.  Eserine  causes  congestion  of  the  ciliary 
processes,  and  probably  this  explains  why,  if  it  do  not 
soon  relieve  glaucoma  by  contracting  the  pupil,  it  some- 
times aggravates  the  symptoms.  It  is  of  use  chiefly  in 
recent,  and  especially  in  acute,  cases.  A  solution  of  one 
or  two  grains  of  the  sulphate  to  the  ounce  is  to  be  used 
from  three  to  six  times  a  day,  or  oftener,  according  to  cir- 
cumstances. The  pain  in  acute  cases  may  be  much  re- 
lieved by  leeching,  warmth  to  the  eye,  and  opium,  with 
derivative  treatment,  such  as  purgation  and  hot  foot-baths. 

Iridectomy  cures  glaucoma  by  permanently  reducing 
the  tension  to  the  normal  or  nearly  normal  pitch,  but  its 
mode  of  action  is  not  fully  known.  It  is  found,  however, 
that  to  ensure  success:  (1)  the  path  of  the  incision  must  lie 


ULAUCOMA.  269 

in  the  sclerotic  from  1  to  2  mm.  from  the  apparent  corneal 
border  (Fig.  85)  ;  (2)  the  wound  should  be  large,-allowing 
removal  of  about  a  fifth  of  the  iris ;  (3)  the  iris  should 
be  removed  quite  up  to  its  ciliary  attachment ;  this  is  best 
done  by  first  cutting  one  end  of  the  loop  of  protruding 
iris,  then  tearing  it  from  its  ciliary  attachment  along  the 
whole  extent  of  the  wound,  and  cutting  through  the  other 
end  separately.  (See  Operations.)  The  evacuation  of  the 
aqueous  humor  by  paracentesis  of  the  anterior  chamber 
gives  only  temporary  relief. 

A  mere  wound  in  the  sclerotic,  differing  but  little  in 
position  and  extent  from  that  made  for  iridectomy,  is  suffi- 
cient to  relieve  -j-  T.,  and  to  cure  many  cases  of  glaucoma 
permanently,  and  this  operation  (subconjunctival  sclerotomy') 
has  been  largely  adopted  by  some  operators  within  the 
last  few  years.  Even  if  the  removal  of  a  piece  of  iris 
should  be  shown  to  be  seldom  necessary,  iridectomy  will 
probably  remain  the  better  operation  for  most  cases,  be- 
cause it  is  easier  to  perform  well.  Sclerotomy  is  open  to 
objection:  (1)  because  the  position  and  length  of  the 
wound  are  not  perfectly  under  control ;  if  too  far  forward 
and  too  short  the  incision  is  insufficient,  if  too  far  back  and 
too  long  there  is  danger  of  wounding  the  ciliary  processes 
and  getting  hemorrhage  into  the  vitreous;  even  shrink- 
ing of  the  operated  eye  and  sympathetic  inflammation  of 
the  other  have  occurred ;  (2)  because  the  iris  may  pro- 
lapse into  the  wound,  and  need  removal,  and  the  opera- 
tion then  becomes  an  iridectomy ;  (3)  when  the  anterior 
chamber  is  very  shallow,  sclerotomy  probably  does  not  aid 
the  exit  of  fluid  so  much  as  the  removal  of  the  iris  does. . 

Several  other  operations,  the  principle  of  which  is  to 
make  a  puncture  at  the  sclero-corneal  junction,  have  been 
tried,  but  have  not  gained  general  confidence. 

Whichever  operation   be   employed   in    glaucoma,   the 
23* 


270  GLAUCOMA. 

formation  of  the  operation  scar  in  the  sclerotic  is  certainly 
a  most  important  factor. 

Iridectomy  in  acute  glaucoma  no  doubt  acts,  at  least  in 
part,  by  removing  a  portion  of  the  iris  from  the  blocked 
angle  (Fig.  85),  and  thus  allowing  the  normal  escape  of  fluid. 
It  is  held  by  some  high  authorities,  however,  that  its  perma- 
nent effect  is  due  to  the  formation  in  the  operation  wound 
of  a  layer  of  tissue  more  pervious  to  the  eye-fluids  than 
the  sclerotic  ("filtration  scar").  The  fact  that  an  iridec- 
tomy  for  glaucoma  which  heals  rather  slowly,  is  thought 
by  many  to  be  more  favorable  than  one  which  heals  im- 
mediately, i.  e.,  with  less  new  tissue,  and  that  a  slight  bulg- 
ing of  the  scar  is  believed  by  some  surgeons  to  be  rather  a 
good  thing  than  otherwise,  are  probably  expressions  of  the 
real  value  of  the  new  tissue  formed  during  somewhat  slow 
healing.  The  curative  effect  of  sclerotomy  points  in  the 
same  direction.  A  scar  of  the  same  character  never  forms 
if  the  incision  be  in  the  cornea. 

An  operation,  usually  iridectomy,  is  to  be  done  in  all 
cases  of  acute  and  subacute  glaucoma,  whether  there  be 
great  pain  or  not,  so  long  as  some  sight  still  remains,  and 
even  if  all  p.  1.  be  abolished,  provided  this  be  only  of  a 
few  days'  duration.  (See  Operations.)  Even  if  the  eye  be 
permanently  quite  blind,  iridectomy  or  sclerotomy  is  some- 
times preferable  to  excision  of  the  globe,  for  the  relief  of 
pain.  (Compare  p.  272,  and  Tumors.) 

In  very  chronic  glaucoma,  when  well  developed,  the  rule 
is  less  clear,  for  it  is  well  known  that  the  effect  of  operation 
in  such  cases  is  far  less  constant,  especially  if  the  visual 
field  be  already  much  contracted.  As  no  other  treatment 
is  of  use,  and  opei'ative  treatment  is  certainly  often  bene- 
ficial, it  should,  as  a  rule,  be  adopted,  the  patient's  judg- 
ment being  allowed  a  fair  weight  in  the  decision.  The 
same  difficulty  occurs  in  some  of  the  so-called  "premoni- 
tory attacks,"  which  are  really  early  transient  attacks  of 


GLAUCOMA.  271 

slight  glaucoma.  When  once  it  is  clear  that  such  attacks 
of  temporary  mistiness  and  rainbows  are  glaucomatous, 
and  that  they  are  getting  more  frequent,  the  operation 
should,  as  a  rule,  not  be  deferred.  An  exception  is, 
however,  to  be  made  if  the  patient  can  be  seen  at  short 
intervals;  eserine  should  then  have  a  fair  trial  before 
operation  is  resorted  to.  It  is  to  be  remembered  that 
iridectomy  done  when  sight  is  still  nearly  perfect  may,  by 
allowing  light  to  pass  through  the  margin  of  the  lens, 
cause  an  increase  of  the  defect  (p.  14)  ;  and  this,  though 
not  of  necessity  a  contra-indication,  must  be  carefully 
taken  into  account.  The  patient's  prospect  of  life  must 
also  be  allowed  for  in  chronic  glaucoma ;  if  he  be  old  and 
feeble,  life  may  end  before  the  disease  has  in  its  natural 
course  caused  blindness. 

THE  PROGNOSIS  after  operation  is,  in  general  terms, 
better  in  proportion  as  the  disease  is  acute  and  recent.  If 
operated  on  within  about  ten  days  of  the  onset  of  acute 
symptoms,  and  provided  there  be  at  least  good  p.  1.  at  the 
time  of  operation,  sight  is  usually  restored  to  the  state  in 
which  it  was  at  the  onset,  i.  e.,  if  the  disease  be  recent, 
nearly  perfect  sight  will  be  restored.  If  an  acute  attack 
occur  in  a  chronic  case,  sight  will  be  improved  more  or 
less;  if  the  case  be  entirely  chronic  Ave  can  only  hope,  as  a 
rule,  to  prevent  it  from  getting  worse.  The  prognosis  in 
acute  cases,  however,  varies  a  good  deal  with  the  severity 
as  well  as  the  acuteness.  In  cases  combining  the  maximum 
of  acuteness  and  severity  (glaucoma  fulminans)  the  opera- 
tion may  be  successful,  even  if  for  a  day  or  two  all  p.  1. 
has  been  abolished. 

The  full  benefit  of  the  operation  is  not  seen  for  several 
weeks,  though  a  marked  immediate  effect  is  produced  in 
acute  cases.  A  slight  degree  of  -f-  T.  sometimes  remains 
permanently  after  operation  in  cases  of  old  standing,  and 
does  not  appear  deleterious,  provided  it  be  very  much  less 


272  GLAUCOMA. 

than  before  the  operation  ;  the  eye  tissues  can  in  some  de- 
gree adapt  themselves  to  increased  pressure. 

A  second  iridectomy  in  the  opposite  direction,  or  a  scle- 
rotomy,  should  be  done  if  the  T.,  having  been  reduced  to 
normal,  or  very  slightly  -f ,  after  the  first  operation,  rises 
definitely,  and  is  accompanied  by  a  return  of  other  symp- 
toms ;  but  several  weeks  should  generally  elapse,  for  slight 
waves  of  glaucomatous  tension  may  occur  during  states  of 
temporary  congestion  or  irritation  before  the  eye  has  fully 
recovered  from  the  first  operation,  and  such  symptoms  may 
generally  be  relieved  by  other  means.  Cases  which  relapse 
definitely  or  which  steadily  get  worse  after  the  first  opera- 
tion are  always  very  grave,  and  the  second  operation  must 
not  be  confidently  expected  to  succeed.  If  after  iridectomy 
in  acute  glaucoma  the  symptoms  are  not  relieved  even  for 
a  time,  or  become  worse,  some  deep-seated  disease  is  to  be 
suspected,  such  as  hemorrhage  from  the  retina  or  choroid, 
or  a  tumor.  (See  Secondary  Glaucoma.) 

OTHER  TREATMENT. — If  we  are  obliged  to  delay  the 
operation,  the  other  means  mentioned  at  p.  268  should  be 
prescribed,  including  eserine  drops  used  many  times  a  day, 
and,  if  possible,  a  paracentesis  of  the  anterior  chamber. 
The  diet  should  as  a  rule  be  liberal,  unless  the  patient  be 
plethoric.  It  is  very  important  to  ensure  sound  sleep  and 
mental  quiet.  After  the  operation,  and  until  the  eye  has 
settled  down  to  a  permanently  quiet  state,  all  causes  likely 
to  induce  congestion  of  the  eyes  must  be  carefully  avoided, 
such  as  use  of  the  eyes,  stooping  and  straining,  prolonged 
ophthalmoscopic  examination,  and  the  use  of  atropine. 
We  should  be  on  the  alert  for  the  earliest  symptoms  in  the 
second  eye  after  operation  on  the  first  (see  p.  266),  and  the 
use  of  eserine  may  be  advisable  as  a  prophylactic. 

In  a  few  cases  of  very  chronic  or  subacute  character 
where  high  increase  of  T.  is  present,  iridectomy  seems  to 
aggravate,  instead  of  arresting,  the  disease,  not  being  fol- 


GLAUCOMA.  273 

lowed  by  even  temporary  benefit,  but  by  persistence  of 
-j-  T.,  increased  irritability,  and  still  further  deterioration 
of  sight  (^'glaucoma  malignum"').  It  is  believed  that  the 
tilting  forward  of  the  lens,  which  sometimes  follows  iri- 
dectomy,  may  help  to  account  for  these  symptoms. 

Glaucoma  may  occur  independently  in  cataractous  eyes ; 
and  in  eyes  from  which  the  lens  has  been  extracted,  with 
or  without  iridectomy. 

Secondary  glaucoma  may  be  acute  or  chronic,  according 
as  it  is  a  consequence  of  active  disease  or  of  sequelae. 
Thus,  chronic  glaucoma  may  be  caused  by  circular  iritic 
synechia  with  bulging  of  the  iris  (p.  139),  and  various 
forms  of  chponic  irido-keratitis  and  irido-cyclitis,  especially 
the  sympathetic  form,  are  liable  to  be  accompanied  by  it. 
It  may  follow  perforating  ulceratiou  of  the  cornea  with 
large  anterior  synechia.  The  eye  often  becomes  tempo- 
rarily glaucomatous  in  the  course  of  traumatic  cataract, 
especially  in  patients  past  middle  life  (p.  180).  In  none 
of  these  cases  is  there  much  danger  of  mistaking  second- 
ary for  idiopathic  glaucoma. 

But  secondary  glaucoma  may  result  from  various  deeper 
changes.  When  the  lens  is  dislocated,  either  behind  or  in 
front  of  the  iris,  it  often  sets  up  glaucoma,  and  sometimes 
of  a  very  severe  type,  apparently  by  pressing  on  the  ciliary 
processes  or  iris.  There  is  generally  the  history  of  a  blow ; 
and  in  posterior  dislocation,  even  if  the  edge  of  the  dis- 
placed lens  cannot  be  seen,  the  iris  is  usually  tremulous 
and  its  surface  often  bulging  at  one  part  and  concave  or 
flat  at  another.  If  we  are  sure  that  a  dislocated  lens  is 
causing  the  symptoms,  it  should  be  extracted  by  a  spoon 
operation  (see  Operations) ;  and  if  lying  in  the  anterior 
chamber,  should  usually  be  removed  (p.  187).  But  in  the 
glaucomatous  state  of  the  eye  after  a  severe  blow  (p.  163) 
it  may  be  impossible  to  feel  sure  of  the  condition  of  the 
lens,  and  then  an  iridectomy  must  be  done  and  the  eye  be 


274  GLAUCOMA. 

watched ;  vitreous  is  very  likely  to  escape  at  the  operation 
if  there  be  dislocation  of  the  lens,  for  the  latter  condition 
implies  rupture  of  the  suspensory  ligament.  Hemorrhage 
into  an  eye  whose  retina  is  detached  (e.  g.,  in  high  degrees 
of  myopia)  may  give  rise  to  acute  glaucoma  with  severe 
pain.  A  glaucomatous  attack  generally  occurs  during  the 
growth  of  an  intraocular  tumor  (p.  281).  There  will  often 
be  nothing  in  the  appearance  of  such  an  eye  to  distinguish 
the  case  from  an  idiopathic  glaucoma  of  the  same  severity 
and  of  long  standing,  for  even  if  the  lens  be  not  opaque) 
and  it  often  is  so,  the  other  media  will  probably  be  too 
hazy  to  allow  an  ophthalmoscopic  examination.  In  almost 
every  case,  however,  the  eye  will  be  quite  blind,  and  will 
be  known  to  have  been  so  for  weeks  or  months,  and  there 
will  also  be  the  negative  fact  that  the  fellow-eye  shows  no 
signs  of  glaucoma.  A  glaucomatous  eye  which,  having 
been  absolutely  blind  for  several  months,  remains  painful 
and  inflamed,  and  the  media  of  which  are  too  opaque  for 
ophthalmoscopic  examination,  should  usually  be  excised  as 
likely  to  contain  a  tumor,  especially  if  there  be  no  pre- 
monitory signs  of  glaucoma  in  the  other  eye.  Tumors  in 
the  eyes  of  children  may  cause  secondary  glaucoma,  but 
in  these  cases  there  is  seldom  any  difficulty  in  assigning 
the  glaucoma  to  its  right  cause.  Secondary  glaucoma  now 
and  then  supervenes  in  cases  of  albuminuric  retinitis,  and 
of  embolism  of  the  retinal  artery,  and  more  commonly  in 
some  forms  of  retinal  and  choroidal  hemorrhage  ("  hemor- 
rhagic  glaucoma").  In  the  last-named  cases  the  diagnosis 
can  sometimes  be  completed  only  after  an  unsuccessful  iri- 
dectomy  has  shown  that  the  case  is  not  a  simple  one. 


TUMOES     AND    NEW    GROWTHS.  275 


CHAPTER    XIX. 

TUMORS   AND    NEW    GROWTHS. 

A.  FOR  TUMORS  AND  GROWTHS  OF  THE  EYELIDS,  see 
Chapter  V.  The  following  may  here  be  added. 

Naevus  may  occur  on  the  eyelids,  and  implicate  the  con- 
junctiva, both  of  the  lids  and  eyeball.  Deep  nsevi  may 
degenerate  and  become  partly  cystic. 

Dermoid  tumors  (cystic)  are  not  uncommon  at  the  outer 
end  of  the  eyebrow ;  more  rarely  they  occur  uear  the  inner 
canthus.  They  lie  beneath  the  orbicularis,  and  the  sub- 
jacent bone  may  be  superficially  hollowed.  They  differ 
from  sebaceous  cysts  in  being  much  deeper  and  in  being 
free  from  the  skin.  They  often  grow  faster  than  the  sur- 
rounding parts,  and  may  then  need  extirpation,  the  thin 
cyst  wall  being  carefully  and  completely  removed  through 
an  incision  parallel  with,  and  situated  in,  the  eyebrow. 
They  contain,  besides  sebaceous  matter,  some  short  hairs. 

B.  TUMORS  AND  GROWTHS  OF  THE  CONJUNCTIVA  AND 
FRONT  OF  THE  EYEBALL. 

Cauliflower  warts,  like  those  on  the  glans  penis,  are 
sometimes  seen  on  the  ocular  and  palpebral  conjunctiva. 
They  have  narrow  pedicles,  and  are  flattened  like  a  cock's 
comb.  They  should  be  snipped  off,  but  fresh  ones  are  apt 
to  spring  up. 

Lupus  of  the  conjunctiva  is  generally  accompanied  by 
lupus  of  the  skin,  and  sometimes  of  the  oral  mucous  mem- 
brane. The  conjunctiva  is  thickened,  irregularly  tuber- 


27G  TUMORS    AND    NEW    GROWTHS. 

cular,  and  very  vascular.  The  disease  very  seldom  attacks 
the  ocular  conjunctiva,  and  is  usually  confined  to  a  part 
of  one  eyelid.  It  is  much  benefited  by  the  usual  local 
treatment  for  lupus. 

The  eyelid,  and  especially  the  tarsus,  is  now  and  then 
the  seat  of  diffused  gummatous  inflammation  in  the  tertiary 
stage  of  syphilis.  The  infiltration  gives  rise  to  a  hard, 
indolent  swelling  of  the  whole  lid  (syphilitic  tarsitis). 
Chancres  and  tertiary  syphilitic  ulcers  may  occur  on  the 
lids  (p.  87). 

Pinguecula  is  a  small  yellowish  spot,  looking  like  adipose 
tissue,  in  the  conjunctiva,  close  to  the  inner  or  outer  edge 
of  the  cornea.  It  consists  of  thickened  conjunctiva  and 
subconjunctival  tissue,  and  contains  no  fat.  It  is  com- 
monest in  old  people,  and  in  those  whose  eyes  are  much 
exposed  to  local  irritants.  It  is  of  no  consequence,  though 
advice  is  often  asked  about  it. 

Pterygiuin  is  a  triangular  patch  of  thickened  conjunc- 
tiva, generally  placed  in  the  palpebral  fissure,  the  apex  of 
which  encroaches  upon  the  cornea.  Pterygiuin  varies 
much  in  thickness,  vascularity,  and  size.  It  is  to  be  dis- 
tinguished from  opacity  of  the  cornea,  and  from  the  cica- 
tricial  band  (symblepharon)  which  often  forms  between  lid 
and  globe  after  burns  or  wounds  of  the  conjunctiva.  It  is 
rare  in  English  practice,  being  seldom  seen  except  in  those 
who  have  spent  some  years  in  hot  countries.  It  is  often 
progressive.  The  best  treatment  is  to  dissect  it  up  from  its 
apex  and  transplant  it  into  a  cleft  in  the  conjunctiva  below 
the  cornea;  this  is  more  effectual  than  excision  or  ligature. 
Adhesion  of  swollen  conjunctiva  to  a  marginal  ulcer  of 
cornea  is  the  starting-point  of  pterygium.  Its  subsequent 
course  has  given  rise  to  much  discussion ;  a  recent  observer 
(Poncet)  thinks  it  due  to  imprisoned  microphytes. 

Small  cysts  with  thin  walls  and  clear  watery  contents, 
sometimes  elongated  and  beaded,  are  not  uncommon  in  the 


TUMORS     AND    NEW    GROWTHS.  277 

ocular  conjunctiva  near  the  inner  and  outer  canthus.  They 
are  probably  formed  by  distention  of  valved  lymphatic 
trunks. 

Dermoid  tumors  (solid)  of  the  eyeball  are  much  scarcer 
than  the  cystic  dermoids  of  the  eyebrow  (p.  274).  They 
are  whitish,  smooth,  hemispherical  and  firm,  and  are  gen- 
erally placed  in  the  palpebral  fissure.  They  may  be  wholly 
on  the  conjunctiva  and  movable,  or  partly  on  the  cornea 
and  fixed.  They  are  solid,  and  hairs  may  grow  from  their 
surface.  They  are  often  combined  with  other  congenital 
anomalies  of  the  eye  or  lids.  When  seated  on  the  cornea 
they  cannot  be  entirely  removed. 

The-  swelling  in  some  cases  of  episcleritis  may  be  mis- 
taken for  a  tumor.  (See  p.  146.) 

Fibro-fatty  growth,  forming  a  yellowish,  lobulated, 
tongue-like  protrusion  from  between  the  lid  and  the  globe, 
is  rather  a  curiosity  than  of  much  importance.  It  gen- 
erally lies  in  front  of  the  lachrymal  gland.  It  is  congenital 
but  is  apt  in  after-life  to  grow  disproportionately. 

Cystic  tumors  may  be  met  with  beneath  the  palpebral 
conjunctiva.  Some  are  caused  by  occlusion,  and  distention 
of  the  duct  of  the  lachrymal  gland  (p.  90),  but  others  can- 
not be  so  explained.  (See  Nsevus.)  Fibrous,  and  even 
bony  tumors  are  occasionally  seen  in  the  substance  of  the 
upper  lid,  perhaps  starting  from  the  tarsus;  and  soft, 
pedunculated  (polypoid)  growths  have  been  met  with  in 
the  sulcus  between  lid  and  globe. 

Malignant  tumors  arise  much  less  commonly  on  the 
front  of  the  eye  than  in  the  choroid  or  retina.  They  may 
be  either  epithelial  or  sarcomatous.  An  injury  is  often 
stated  to  be  the  cause  of  the  growth. 

Epithelioma  may  begin  on  the  ocular  conjunctiva,  in 
which  case  it  remains  movable,  or  at  the  sclero-corneal 
junction,  when  it  quickly  encroaches  on  the  cornea,  in- 
filtrates its  superficial  layers  and  becomes  fixed.  It  may 

24 


278      TUMOES  AND  NEW  GROWTHS. 

be  pigmented.  When  such  a  growth  is  not  seen  until  late, 
it  may  perhaps  be  as  large  as  a  walnut,  may  cover  or  sur- 
round the  cornea,  and  present  a  papillary  or  lobulated 
surface,  and  the  glands  in  front  of  the  ear  may  be  enlarged. 

Sarcoma  in  this  region  may  or  may  not  be  pigmented. 
It  generally  arises  at  the  sclero-corneal  junction,  and  when 
small  the  conjunctiva  is  traceable  over  the  growth.  But 
in  advanced  cases  it  may  be  impossible  from  the  clinical 
features  to  diagnose  the  nature  of  a  tumor  in  this  part. 

Movable  tumors  (epithelioma)  not  involving  the  cornea 
may  be  cut  off,  but  are  very  likely  to  recur ;  and  recurrence 
is  still  more  likely  in  the  case  of  growths  fixed  to  the 
cornea  or  sclerotic.  Removal  of  the  eyeball  at  an  early 
date,  especially  in  the  case  of  sarcomata,  is  the  best  course 
in  the  majority  of  cases. 

The  lachrymal  sac  is  occasionally  the  seat  of  new  growth, 
which  may  be  mistaken  for  chronic  mucocele  (p.  91). 

C.  TUMORS  OF  THE  ORBIT. 

A  tumor  of  any  notable  size  in  the  orbit  always  causes 
protrusion  of  the  eye  (jproptosis),  with  or  without  lateral 
displacement  and  limitation  of  its  movement.  As  a  rule, 
there  are  no  inflammatory  symptoms  (see  exceptions  below). 
It  is  obvious  that  the  diagnosis  of  the  size,  attachments, 
and  nature  of  growths  in  the  orbit,  must  often  be  left  open, 
since  the  deep  parts  of  this  cavity  cannot  be  explored. 

A  tumor  in  the  orbit  may  have  originated  in  some  of  the 
loose  orbital  tissues,  in  the  lachrymal  gland,  in  the  peri- 
osteum, upon  or  within  the  eyeball,  or  from  the  optic 
nerve ;  or  it  may  have  encroached  upon  the  orbit  from  one 
of  the  neighboring  cavities.  Tumors  in  the  orbit  when 
fluctuating  may  be  either  cystic  or  ill-defined,  and  may  or 
may  not  pulsate.  They  may  be  solid,  and  either  movable 
or  fixed  by  broad  attachments  to  the  wall  of  the  cavity. 


ORBITAL     TUMORS.  279 

Sight  is  often  damaged  or  destroyed  in  the  corresponding 
eye  by  compression  or  by  infiltration  of  the  optic  nerve. 
(See  Intraocular  Tumors.) 

(1)  Distention  of  the  frontal  sinus  by  retained  mucus 
causes  a  well-marked,  fixed,  usually  very  chronic  swelling, 
not  adherent  to  the  skin,  at  the  upper  inner  angle  of  the 
orbit  above  the  tendo  oculi.     At  first  hard,  when  advanced 
it  fluctuates.     Its  course  is  usually  slow,  but  acute  suppura- 
tion may  supervene,  and  the  swelling  be  mistaken  for  a 
lachrymal  abscess  (p.  92).    There  is  generally  a  history  of 
injury.     The  aim  of  treatment  is  to  reestablish  a  perma- 
nent opening  between  the  floor  of  the  sinus  and  the  nose. 
The  most  prominent  part  of  the  swelling  is  freely  opened ; 
a  finger  is  passed  up  the  nostril,  and  the  floor  of  the  dis- 
tended sinus  perforated  on  the  finger  by  a  trocar  introduced 
from  above.     A  thick  seton  or  small  drainage-tube  is  then 
passed  through  the  hole  so  made  and  brought  out  at  the 
nostril ;  it  must  be  worn  for  several  weeks  or  months. 

(2)  Ivory  exostoses  sometimes  grow  from  the  walls  of 
the  same  sinus  or  from  neighboring  parts,  beginning  com- 
paratively early  in  life,  increasing  very  slowly,  and  causing 
absorption  of  some  portions  of  their  containing  walls.     In 
removing  these  tumors  there  is  serious  danger  of  fracturing 
the  cranial  walls  of  their  containing  cavity,  and  wounding 
the  dura  mater. 

(3)  Tumors  encroaching  on  one  or  both  orbits  from  the 
base   of  the  skull,  the  antrum,  the  nasal  cavity,  or  the 
temporal  fossa,  generally  admit  of  correct  diagnosis,  but 
their  treatment  does  not  belong  to  the  ophthalmic  surgeon. 
The  suspicion  of  tumor  on  the  inner  or  lower  wall  of  the 
orbit  should  always  lead  the  ophthalmic  surgeon  to  an  ex- 
amination of  the  palate,  pharynx,,and  teeth,  of  the- permea- 
bility of  each  nostril,  of  the  functions  of  the  cranial  nerves, 
of  the  state  of  the  glands  behind  the  jaw  on  both  sides,  and 
.to  an  inquiry  as  to  epistaxis  or  discharge  from  the  nose. 


280  TUMORS     AND    NEW    GROWTHS. 

(4)  Pulsating  tumors  of  the  orbit  and  cases  of  prop- 
tosis  with,  pulsation   are  probably  in  most  cases  due  to 
arterio-venous  intercommunication  in  the  cavernous  sinus, 
in   consequence  of  which   the   ophthalmic   vein   and   its 
branches  become  greatly  distended  with   partly  arterial 
blood.     In  a  large  number  the  symptoms  have  followed 
rather  gradually  after  a  severe  injury  to  the  head,  whilst 
in  others  they  come  on  suddenly  with  pain  and  noises  in 
the  head,  without  apparent  cause.     These  idiopathic  cases 
are  usually  in  senile  persons.     In   several  examples  of 
both  forms  a  communication  has  been  found  post  mortem 
between  the  internal  carotid  and  the  cavernous  sinus,  the 
result  of  wound  from  fracture  of  the  base  of  the  skull  in 
the  traumatic  cases  and  of  rupture  of  an  aneurism  in  the 
idiopathic  ones.     The  typical  symptoms  are  proptosis,  with 
chemosis,   pulsation  of  the   eyeball,  paralysis  of   orbital 
nerves,  a  soft  pulsating  tumor  under  the  inner  part  of  the 
orbital  arch,  and  a  bruit.     A  bruit  with  proptosis  and 
conjunctival  swelling  may  be  present,  without  demonstra- 
ble tumor  or  pulsation.     Ligature  of  the  common  carotid 
has  been  practised  with  good  results  in  a  large  number  of 
cases  of  pulsating  exophthalmos,  but   the   treatment   of 
these  cases  does  not   belong  to  the  ophthalmic  surgeon. 
The  symptoms  above  described  are  not  caused  by  unrup- 
tured  aneurism  of  the  internal  carotid.     Aneurism  of  the 
intra-orbital  arteries  and  arterio-venous  communications  in 
the  orbit,  if  they  occur,  are  excessively  rare.     Erectile 
tumors,  well-defined  and  separable,  but  not  causing  de- 
cided pulsation,  are  sometimes  met  with  in  the  orbit,  and 
can  be  dissected  out. 

(5)  A  tumor  which  fluctuates  but  does  not  pulsate,  is 
free   from   inflammatory   symptoms,   and    not   connected 
with  the  frontal  sinus,  may  be  a  chronic  orbital  abscess 
(see  also  p.   89),  a  hydatid,  or  a  cyst  containing  bloody 
or  other  fluid  and  of  uncertain  origin.     An  exploratory 


ORBITAL     TUMORS.  281 

puncture  should  be  made  after  sufficiently  watching  the 
case,  and  the  further  treatment  must  be  conditional.  Per- 
fectly clear,  thin  fluid  probably  indicates  a  hydatid,  and 
in  this  case  the  swelling  is  likely  to  return  after  puncture 
and  the  cyst  will  need  removal  through  a  free  opening. 
The  echinococcus  hydatid  often  contains  daughter-cysts, 
some  of  which  escape  puncture.  Suppuration  may  take 
place  around  any  species  of  hydatid. 

(6)  Examination  leads  to  the  diagnosis  of  a  solid  tumor 
limited  to  the  orbit.  We  must  try  to  determine  whether 
the  growth  began  in  the  eyeball  or  optic  nerve,  or  in  some 
of  the  surrounding  tissues.  We  therefore  examine  the 
globe  for  symptoms  of  intraocular  tumor.  (See  below.) 

Solid  growths  independent  of  the  eyeball  may  arise  as 
follows :  (a)  From  the  periosteum ;  these  are  firmly  at- 
tached by  a  broad  base,  are  generally  malignant,  and 
seldom  admit  of  successful  removal.  (6)  The  lachrymal 
gland  (compare  p.  89)  is  the  seat  of  various  morbid 
growths,  including  carcinoma ;  a  great  part  of  the  growth 
is  in  the  position  of  the  gland,  and  can  be  explored  by 
the  finger.  Although  such  a  growth  is  often  attached 
firmly  to  the  orbital  wall,  its  position,  lobulated  outline, 
and  well-defined  boundary  will  often  lead  to  a  correct 
diagnosis.  Tumors  of  the  lachrymal  gland  should  always 
be  removed  if  they  are  increasing ;  for  we  can  never  feel 
sure  that  they  are  innocent,  (c)  Solid  tumors  originating 
in  some  of  the  softer  orbital  tissues,  especially  the  form 
known  as  cylindroma,  or  plexiform  sarcoma,  occur  more 
rarely,  (d)  Tumors  of  the  optic  nerve,  usually  myxoma- 
tous,  occur,  though  rarely;  th^.y  generally  cause  neuro- 
retinitis  and  blindness,  but  no  absolute  pathognomonic 
symptoms ;  they  may  sometimes  be  extirpated  without 
removing  the  globe. 

When  an  orbital  tumor  is  found  during  operation  to  be 
adherent  to  the  wall  or  to  infiltrate  the  tissues  around  it, 

24* 


282      TUMORS  AND  NEW  GROWTHS. 

chloride  of  zinc  paste  should  be  applied  on  strips  of  lint, 
either  at  once,  or  the  next  day  when  oozing  has  ceased. 
If  the  periosteum  be  affected,  it  is  to  be  stripped  off,  and 
the  paste  applied  to  the  bare  bone.  Hemorrhage  from  the 
depth  of  the  orbit  can  always  be  controlled  by  perchloride 
of  iron  and  a  firm  graduated  compress. 

In  every  case  of  suspected  primary  orbital  tumor  (unless 
it  be  quite  clearly  limited  to  the  lachrymal  gland)  the 
question  of  syphilis  must  be  carefully  gone  into.  Neither 
periosteal  nor  cellular  nodes  are  common  in  the  orbit,  but 
both  occur  and  disappear  under  proper  treatment. 

D.  INTRAOCULAR  TUMORS. 

By  far  the  commonest  forms  are  glioma  of  the  retina 
and  sarcoma  of  the  choroid. 

Giioma  of  the  retina  is  always  a  disease  of  infancy  or 
early  childhood,  the  patients  being  generally  under  two 
years  old  when  first  brought  for  treatment ;  it  may,  how- 
ever, be  present  at  birth,  and  may  begin  as  late  as  the 
eleventh  or  twelfth  year.  Glioma  is  very  soft,  composed 
of  small,  round  cells  which  grow  from  the  granule  layers 
of  the  retina,  and  it  either  grows  outwards,  causing  detach- 
ment of  the  retina,  or  inwards  into  the  vitreous;  often 
several,  more  or  less  separate,  lobules  are  present.  It  runs 
a  comparatively  quick  course,  filling  the  eyeball  in  a  few 
months,  spreading  by  contact  to  the  choroid,  and  thence  to 
the  sclerotic  and  orbit.  It  is  especially  prone  to  travel 
back  along  the  optic  nerve  to  the  brain ;  and  it  may  cause 
secondary  deposits  in  the  brain  and  in  the  scalp,  and  more 
rarely  in  distant  parts.  If  the  eye  be  removed  before 
either  the  optic  nerve  or  the  orbital  tissues  are  infiltrated, 
the  cure  is  radical,  but  in  the  more  numerous  cases,  where 
the  patient  is  not  seen  till  what  may  be  called,  clinically, 
the  second  stage  (see  below),  a  fatal  return  occurs  in  the 


INTRAOCULAR     TUMORS.  283 

orbit  or  within  the  skull.  Glioma  sometimes  occurs  in 
both  eyes  one  after  the  other,  and  in  several  children  of 
the  same  parents. 

The  earliest  symptom  is  a  shining  whitish  appearance 
deep  in  the  eye,  and  the  eye  is  soon  noticed  to  be  blind ; 
as  there  is  neither  pain  nor  redness,  advice  is  seldom 
sought  at  this  stage.  If  examined,  T.  is  found  to  be  n.  or 
rather  — .*  When  the  peculiar  appearance  has  become  very 
striking  or  the  eye  becomes  painful,  the  child  is  brought. 
In  this  (the  second)  stage  there  is  generally  some  conges- 
tion of  the  scleral  vessels,  and  a  white,  pink,  or  yellowish 
reflection  from  behind  the  lens  (which  remains  clear), 
steaminess  of  the  cornea,  mydriasis,  T.  -J-,  anterior  chamber 
of  uniform  depth ;  there  may  be  enlargement  or  promi- 
nence of  the  eyeball.  On  focal  examination  some  vessels 
can  generally  be  seen  on  the  whitish  background,  and  white 
specks  of  calcareous  degeneration  are  sometimes  present. 

Cases  are  not  uncommon  in  young  children  in  which  the 
above  appearances  are  simulated  by  inflammatory  changes 
in  the  vitreous,  with  detachment  of  the  retina;  and  the 
differential  diagnosis  is  occasionally  difficult.  In  these 
pseudo-glioma  cases  iritic  adhesions  are  present,  T.  is  — , 
the  eye  usually  somewhat  shrunken,  the  anterior  chamber 
deep  at  its  periphery,  whilst  absent  or  shallow  at  the  centre. 
There  is  often  the  history  of  a  definite  inflammatory  attack 
with  acute  cerebral  symptoms,  preceding  the  peculiar  ap- 
pearance in  the  pupil.  When  in  any  doubt,  the  eye  should 
be  excised. 

Sarcoma  of  the  choroid  and  ciliary  body  is  a  growth  of 
late  or  middle  life,  being  rarely  seen  below  the  age  of 
thirty-five.  The  majority  of  these  tumors  are  pigmented 
(melanotic),  some  being  quite  black,  others  mottled  or 

1  The  occurrence  of  slightly  reduced  T.  in  the  earliest  stage  of 
glioma  was  first  pointed  out  to  me  by  Dr.  Brailey. 


284  TUMORS     AND    NEW    GROWTHS. 

streaked.  A  few  are  quite  free  from  pigment.  Some  are 
spindle-celled  or  mixed,  others  composed  of  round  cells ; 
some  are  truly  alveolar,  but  in  many  specimens  there  is 
very  little  connective-tissue  stroma,  and  no  very  defined 
arrangement  of  the  cells.  These  tumors  are  moderately 
firm  but  friable;  some  are  very  vascular,  and  hemorrhages 
often  occur  in  them.  The  tumor  generally  grows  from  a 
broad  base,  and  forms  a  well-defined  rounded  prominence, 
pushing  the  retina  before  it ;  blood  or  serous  fluid  is  gen- 
erally effused  round  its  base,  so  that  the  retinal  detachment 
is  much  more  extensive  than  the  tumor.  These  tumors 
often  grow  slowly  so  long  as  they  are  wholly  contained 
within  the  eye,  and  two,  three,  or  more  years  may  pass  be- 
fore the  growth  passes  out  of  the  eye  and  invades  the  orbit. 
Though  this  does  not  usually  occur  till  the  globe  is  filled 
to  distention  by  the  growth,  it  may  happen  much  earlier,  the 
cells  passing  out  along  the  sheaths  of  the  perforating  blood- 
vessels, and  producing  large  extraocular  growths,  while 
the  intraocular  primary  tumor  is  still  quite  small.  The 
lymphatic  glands  do  not  enlarge,  but  there  is  great  danger 
of  secondary  growths  in  distant  parts,  especially  in  the 
liver,  a  risk  not  entirely  absent,  even  when  the  eye  tumor 
is  quite  small.  Hence  early  removal  of  the  globe  is  of  the 
utmost  importance,  and  a  good,  though  not  too  confident, 
prognosis  may  be  given  when  the  optic  nerve  and  tissues 
of  the  orbit  show  no  signs  of  disease. 

SYMPTOMS  AND  COURSE. — If  the  case  be  seen  early, 
when  defect  of  sight  is  the  only  symptom,  the  tumor  can 
often  be  seen  and  recognized  by  its  well-defined  rounded 
outline,  some  folds  of  detached  retina  often  being  visible 
near  it.  The  pupil,  cornea,  and  eye-tension  will  probably 
be  quite  natural.  But  sooner  or  later  the  tumor  in  its 
growth  sets  up  symptoms  of  acute  or  subacute  glaucoma 
and  sometimes  iritis;  subsequently  secondary  cataract 
forms.  It  is  in  the  glaucomatous  (second)  stage  that  relief 


INTRAOCULAR     TUMORS.  285 

is  usually  sought.  Unless  some  part  of  the  tumor  happen 
to  be  visible  outside  the  sclerotic,  or  project  into  the  an- 
terior chamber,  a  positive  diagnosis  often  cannot  now  be 
given  owing  to  the  opacity  of  the  media,  although  by  ex- 
clusion we  may  often  arrive  at  great  probability.  If  the 
eye  be  left  alone,  or  iridectomy  be  performed,  glaucomatous 
attacks  and  pain  will  recur,  and  the  eye  will  enlarge  and 
gradually  be  disorganized  by  the  increasing  growth,  which 
will  then  quickly  fill  the  orbit  and  fungate.  But  sometimes 
a  deceptive  period  of  quiet  follows  the  glaucomatous  attack, 
and  perhaps  even  some  shrinking  and  reduction  of  tension 
may  occur,  after  which  the  growth  makes  a  fresh  start  and 
becomes  apparent.  It  is  chiefly  in  very  old  patients  that 
this  slow  course  is  noticed.  Sarcoma  is  especially  likely  to 
form  in  eyes  previously  injured,  or  already  shrunken  from 
disease. 

Thus  it  is  apparent  that  in  a  majority  of  cases  the  pres- 
ence of  choroidal  tumor  can  only  be  conjectured.  We 
suspect  a  tumor  and  urge  excision  in  the  following  cases : 

(1)  When  an  eye  that  has  been  for  some  time  failing  or 
blind  from  deep-seated  disease  becomes  painful,  congested, 
and  glaucomatous  (there  being  no  glaucoma  of  the  other 
eye),  and  particularly   if   there  be  secondary   cataract. 

(2)  Similar  eyes  with  normal  or  diminished  tension  are 
best  excised,  as  possibly  containing  tumor.     (3)  In  exten- 
sive detachment  of  retina  confined  to  one  eye,  without 
history   of   injury   or   evidence  of   myopia,   the    patient 
should  be  warned,  or  the  eye  excised,  according  to  cir- 
cumstances. 

In  all  suspicious  cases  the  cut  end  of  the  optic  nerve  of 
the  excised  eye  should  be  carefully  looked  at,  and  if  it  be 
pigmented  or  thickened  another  piece  should  be  at  once 
removed,  and  the  orbit  searched  by  the  finger  for  evidence 
of  growth ;  the  surface  of  the  eye  should  also  be  carefully 
examined  for  external  growths.  When  infection  of  the 


286  TUMORS     AND    NEW    GROWTHS. 

nerve  or  orbit  is  suspected  chloride  of  zinc  should  be  ap- 
plied as  already  directed. 

Tubercular  growths  of  large  size  may  occur  in  the 
choroid.  The  diagnosis  is  uncertain  till  after  excision,  and 
the  treatment  differs  in  no  way  from  that  of  malignant 
growths.  The  patients  are  generally  young. 

Tumors  of  the  iris  are  rare.  Melanotic  as  well  as  un- 
pigmented  sarcomata  are  occasionally  met  with.  Sebaceous 
or  epithelial  tumors  are  also  seen ;  they  are  nearly  always 
the  result  of  transplantation  of  epithelium,  or  even  of  a 
hair,  into  the  iris  through  a  perforating  wound  of  the 
cornea.  In  rare  cases  cystic  tumors  with  thin  walls  are 
formed  in  connection  with  the  iris,  particularly  in  eyes 
which  have  been  operated  on  for  cataract. 

The  term  granuloma  is  applied  to  several  forms  of  non- 
malignant  tumor  of  the  iris,  some  of  which  are  large 
tubercles,  some  syphilitic  gummata  of  large  size,  and  some 
true  granulation  tissue  following  wounds.  These  forms  are 
all  accompanied  by  iritis. 


REFRACTION    AND    ACCOMMODATION.       287 


CHAPTER  XX. 

ERRORS    OF  REFRACTION  AND  ACCOMMODATION. 

As  stated  at  p.  25,  §  19,  when  the  length  of  the  eye  is 
normal  and  the  accommodation  relaxed,  only  parallel  rays 
are  focussed  on  the  retina,  and  conversely  pencils  of  rays 
emerging  from  the  retina  are  parallel  on  leaving  the  eye 
(Fig.  87,  and  pp.  17  and  18,  §§  11  and  12),  and  this,  the 

JIG.  87. 


Pencils  of  parallel  rays  entering  or  emerging  from  emmetropic  eye. 


condition  of  the  normal  eye  in  distant  vision,  is  called  em- 
metropia  (E).  All  permanent  departures  from  the  condi- 
tion in  which,  with  relaxed  accommodation,  the  retina  lies 
at  the  principal  focus  are  known  collectively  as  ametropia. 

FIG.  88. 


Emmetropia. — Distant  objects  (parallel  rays)  focussed  on  retina;  near 
objects  (divergent  rays)  focussed  behind  retina. 

In  E.  rays  from  any  near  object,  e.  g.y  divergent  rays  from 
Ob,  Fig.  88,  are  focussed  behind  the  retina  at  CF,  every 


288       REFRACTION    AND    ACCOMMODATION. 

conjugate  focus  being  beyond  the  principal  focus  (p.  18, 
§  13).  Reaching  the  retina  before  focussing,  such  rays  will 
form  a  blurred  image,  and  the  object  Ob  will  therefore  be 
seen  dimly.  But  by  using  accommodation  the  convexity 
of  the  crystalline  lens  can  be  increased  and  its  focal  length 
shortened,  so  as  to  make  the  conjugate  focus  of  Ob  coincide 
exactly  with  the  retina  (CF,  Fig.  89).  Under  this  condition 
the  object  Ob  will  be  clearly  seen,  whilst  the  focus  of  a 

FIG.  89. 


Eye  during  accommodation. — Near  objects  (divergent  rays)  focussed  on 
retina;  distant  objects  (parallel  rays)  focussed  in  front  of  retina.  Dotted 
line  in  front  of  lens  shows  its  increase  of  convexity. 

distant  object,  which  in  Fig.  88  was  formed  on  the  retina, 
will  now  lie  in  front  of  it  (F,  Fig.  89),  and  the  distant  ob- 
ject will  appear  indistinct.  The  nearest  point  of  distinct 
vision  (p.)  and  the  farthest  (r.)  have  been  defined  at  p.  44. 

MYOPIA.    (M.) 

In  Fig.  88,  if  the  retina  were  at  CF  instead  of  at  F,  a 
clear  image  would  be  formed  of  an  object  at  Ob,  without 
any  effort  of  accommodation,  whilst  objects  farther  off 
would  be  focussed  in  front  of  the  retina.  This  state,  in 
which  the  posterior  part  of  the  eyeball  is  too  long,  so  that, 
with  the  accommodation  at  rest,  the  retina  lies  at  the  con- 
jugate focus  of  an  object  at  a  comparatively  small  distance, 
is  called  Short-sight  or  Myopia  (M.)  (Axial  Myopia). 

In  Fig.  90  the  inner  line  at  K  is  the  retina,  and  F  the 
principal  focus  of  the  lens-system,  i.  e.,  the  position  of  the 
retina  in  the  normal  eye.  Rays  emerging  from  R  will,  on 


MYOPIA.  289 

leaving  the  eye,  be  convergent,  and,  meeting  at  the  conju- 
gate focus  it',  will  form  a  clear  image  in  the  air.  Con- 
versely, an  object  at  R'  will  form  a  clear  image  on  the 
retina  (R)  (compare  Figs.  9  and  11).  The  image  of  every 
object  at  a  greater  distance  than  R'  will  be  formed  more  or 
less  in  front  of  R,  and  every  such  object  must,  therefore,  be 

FIG.  90. 


Myopia. — Retina  beyond  principal  focus,  hence  only  near  objects 
(divergent  rays)  focussed  on  retina. 

seen  indistinctly.  But  objects  nearer  than  R'  will  be  seen 
clearly  by  exerting  accommodation,  just  as  in  the  normal 
eye  (Figs.  88  and  89,  and  p.  44). 

In  myopia  the  indistinctness  of  objects  beyond  the  far 
point  (r)  is  lessened  by  partly  closing  the  eyelids.  This 
habit  is  often  noticed  in  short-sighted  people  who  do  not 
wear  glasses,  and  from  it  the  word  myopia  is  derived. 

The  distance  of  r  (V,  Fig.  90)  from  the  eye  will  depend 
on  the  distance  of  its  conjugate  focus  R,  i.  e.,  upon  the 
amount  of  elongation  of  the  eye.  The  greater  the  distance 
of  R  beyond  F,  the  less  will  be  the  distance  of  its  conjugate 
focus  R'  (=  r);  in  other  words,  the  higher  will  be  the 
myopia,  and  the  more  indistinct  will  distant  objects  be. 
If  the  elongation  of  the  eye  be  very  slight,  R  nearly  coin- 
ciding with  F,  R'  (=  r)  will  be  at  a  much  greater  distance 
(compare  p.  19,  §  16),  and  distant  objects  will  be  less  indis- 
tinct. As  the  retinal  images  formed  in  a  myopic  eye  are 
larger  than  normal  (p.  25,  §  19),  myopic  persons  can  dis- 
tinguish smaller  objects  at  the  same  distance  than  those 

with  normal  eyes. 

25 


290        REFRACTION    AND    ACCOMMODATION. 

SYMPTOMS  OF  M. — In  low  degrees  the  patient's  com- 
plaint is  that  he  cannot  see  distant  objects  clearly ;  in 
moderate  and  high  degrees  it  is  rather  that  he  can  see 
distinctly  only  when  things  are  held  very  close,  for  objects 
a  few  feet  off  are  so  indistinct  that  many  such  persons 
neglect  them.  Adults  often  tell  us  that  their  distant  sight 
was  good  till  about  eight  or  ten  years  of  age,  that  it  then 
began  to  shorten,  and  that  the  defect  after  increasing  for 
several  years  at  length  became  stationary. 

In  many  cases,  no  other  complaint  is  made ;  but  in  a 
certain  number  complications  are  present.  There  is  often 
intolerance  of  light,  an  additional  cause  for  the  half-closed 
lids  and  frowning  expression  so  often  noticed.  Aching  of 
the  eyes  is  a  very  common  and  troublesome  symptom,  and 
is  especially  frequent  if  the  myopia  is  increasing ;  it  is  often 
brought  on  and  always  made  worse  by  over-use  of  the  eyes, 
but  sometimes  is  very  troublesome  when  quite  at  rest,  and 
even  in  bed  at  night.  One  or  both  internal  recti  often  act 
deficiently  in  myopia,  so  that  convergence  of  the  optic  axes 
for  near  vision  becomes  difficult,  painful,  or  impossible,  and 
various  degrees  of  divergent  strabismus  result ;  this  occurs 
oftenest,  but  by  no  means  only,  in  the  higher  degrees  of  M. 
where  r  is  so  near  that  binocular  vision  involves  a  strong 
effort  of  convergence.  When  this  "muscular  asthenopia" 
or  "insufficiency  of  the  internal  recti"  is  slight  or  inter- 
mittent it  causes  indistinctness,  "  dancing,"  and  sometimes 
actual  diplopia,  besides  the  other  discomforts  above  men- 
tioned ;  but  diplopia  is  seldom  present  when  a  constant 
divergent  squint  has  been  established.  The  lower  degrees 
of  M.  are  sometimes  accompanied  by  involuntary  contrac- 
tion of  the  ciliary  muscle  ("spasm  of  accommodation  ")  by 
which  M.  is  temporarily  increased ;  and  the  habitual 
approximation  of  objects  which  thus  becomes  necessary  is 
one  cause  of  still  further  elongation  of  the  eye  and  in- 


MYOPIA.  291 

crease  of  the  structural  M.  Floating  specks  (muscce  voli- 
tantes,  p.  247)  are  especially  common  and  troublesome  in 
myopia. 

Objective  signs  and  complications. — In  high  degrees  of  M. 
the  sclerotic  is  enlarged  in  all  directions  (Fig.  91) ;  the  eye 

FIG.  91. 


Section  of  a  highly  myopic  eyeball.     The  retina  has  been  removed. 


often  looks  too  prominent  or  too  large,  and  its  movements 
are  somewhat  impeded.  But  apparent  prominence  of  the 
eye  may  depend  on  many  other  causes  (p.  34,  6). 

The  existence  of  myopia  is  made  certain  by  the  ophthal- 
moscope in  four  different  ways.  (1)  By  direct  examination, 
the  image  of  the  fundus  formed  in  the  air  (Fig.  90)  is 
clearly  visible  to  the  observer,  if  he  be  not  nearer  to  it 
than  his  own  near  point,  p.  The  image  is  inverted  and 
magnified,  the  enlargement  being  greater  the  further  it  is 
formed  from  the  patient's  eye  (p.  21,  §  17),  i.  e.,  the  lower 
the  M.  For  very  low  degrees  this  test  is  not  easy  to  use, 
because  of  the  great  distance  (3'  or  4',  e.  <?.)  that  must  inter- 
vene between  observer  and  patient ;  but  it  is  easily  applied 
if  the  image  be  not  more  than  2'  in  front  of  the  patient 
(compare  pp.  62,  A,  and  73,  2). 

(2)  By  indirect  examination  the  disk  in  M.  appears 
smaller  than  usual.  If,  now,  the  object  lens  be  gradually 
withdrawn  from  the  patient's  eye,  the  disk  will  seem  to 
grow  larger.  This  appearance,  which  depends  on  a  real 


292       REFRACTION    AND     ACCOMMODATION 

increase  in  the  size  of  the  aerial  image  (Fig.  29),  is  less 
evident  the  lower  the  M.1 

(3)  By  direct  examination  no  clear  view  of  the  fundus 
is  obtained  if  the  distance  between  patient  and  observer 
be  less  than   that   between   patient   and   inverted  aerial 
image  (Figs.  28  and  89,  R')  ;  and  as  R'  is  always  in  front 
of  the  myopic  eye,  the  image  will  necessarily  be  invisible 
if  the  observer  go  close  to  the  patient.     Hence,  if  on  going 
close  to  the  patient  the  observer  cannot,  either  by  relaxing 
or  using  his  accommodation  (see  p.  73),  see  any  details  of 
the  fundus  clearly,  the  patient  is  myopic  (opacities  of  the 
media  being,  of  course,  excluded).     This  test  is  applicable 
to  all  degrees  of  M.,   accommodation   being   completely 
relaxed  (see  also  p.  298).     The  tests  (1)  and  (2)  are  on 
the  whole  most  generally  useful  for  beginners. 

(4)  By  retinoscopy  (p.  78),  the  shadow  obtained  on  rotat- 
ing the  mirror  moves  in  the  direction  of  the  rotation. 


Myopic  crescent  or  small  posterior  staphyloma.     (Wecker  and  Jaeger.) 

In  a  large  proportion  of  cases  the  elongation  of  the  eye 
causes  atrophy  of  the  choroid  on  the  side  of  the  optic  disk 
next  to  the  y.  s.  (the  apparent  inner  side  in  indirect  ex- 
amination). This  atrophy  gives  rise  to  a  crescentic  patch 

1  The  explanation  of  this  increase,  and  of  the  corresponding 
decrease  in  H.  (p.  306),  would  require  separate  diagrams  and 
occupy  too  much  space. 


MYOPIA.  293 

(Fig.  92)  of  yellowish-white  or  grayish  color,  whose  con- 
cavity is  the  border  of  the  disk,  whilst  its  convex  side 
curves  towards  the  y.  s.,  and  it  is  commonly  known  as  the 
"  myopic  crescent."  It  is  also  called  a  "  posterior  staphy- 
lorna"  (p.  199)  because  it  indicates  a  localized  bulging  of 
the  sclerotic  (Fig.  91).  It  varies  in  size  from  the  nar- 
rowest rim  to  an  area  several  times  that  of  the  disk,  and 
may  form  a  zone  entirely  surrounding  the  disk  (Fig.  93) 
instead  of  a  crescent ;  there  may  also  be  separate  spots  of 
atrophy  or  diffused  thinning  of  the  choroid,  beyond  the 
bounds  of  the  crescent,  especially  in  a  horizontal  direction 

FIG.  93. 


Large  annular  posterior  staphyloma.     (Liebreich.) 

towards  the  y.  s.  As  a  rule,  the  higher  the  myopia  the 
more  extensive  are  these  choroidal  changes,  but  the  rela- 
tion is  by  no  means  a  constant  one,  and  occasionally  even 
in  high  degrees  we  find  no  crescent.  Hemorrhages  may 
occur  from  the  choroid  in  the  same  region,  and  leave  some 
residual  pigment  (pp.  192  and  196).  Owing  to  the  steep- 
ness of  the  bulging,  the  disk  is  often  tilted  and  appears 
oval,  because  seen  at  "  three-quarter  face"  instead  of"  full 
face "  (Fig.  93).  It  is  sometimes  very  pale  and  atrophic 
on  the  side  next  the  y.  s.  when  the  staphyloma  is  large. 

25* 


294       REFRACTION    AND    ACCOMMODATION. 

There  is  in  myopia  a  great  liability  to  liquefaction  of, 
and  the  formation  of  opacities  in,  the  vitreous,  and,  still 
worse,  to  detachment  of  the  retina.  A  very  large  propor- 
tion of  all  the  retinal  detachments  occur  in  myopic  eyes. 
A  blow  on  the  eye  often  appears  to  have  caused  the  de- 
tachment, though  often  not  until  after  a  considerable  in- 
terval. In  high  degrees  of  M.  the  lens  frequently  becomes 
cataractous,  the  cataract  generally  being  cortical  and  com- 
plicated with  disease  of  the  vitreous  (pp.  175,  211,  etc.). 

Thus  we  arrive  at  a  sum  total  of  serious  difficulties  and 
risks  to  which  myopic  persons  are  subject,  especially  when 
the  myopia  is  of  high  degree.  It  is  only  when  the  degree 
is  low  (2  D.  or  less),  and  the  condition  stationary,  that  the 
popular  idea  of  "  short  sight "  being  "  strong  sight "  is  at 
all  borne  out,  or  that  the  later  onset  of  presbyopia  (p.  317) 
counterbalances  the  disadvantages  of  bad  distant  vision. 

CAUSES. — M.  is  sometimes  present  at  birth,  but  much 
more  commonly  the  eye  begins  to  elongate  during  child- 
hood. Though  the  tendency  to  M.  is  strongly  hereditary, 
it  often  begins  afresh,  especially  from  the  prolonged  use  of 
the  eyes  for  near  work.  The  strain  on  the  internal  recti, 
counterbalanced,  it  may  be,  by  a  corresponding  tension  on 
the  external  recti,  is  believed  to  act  by  compressing  the 
eyeball,  and  thus  causing  the  unprotected  posterior  pole  of 
the  sclerotic  to  bulge.  The  concomitant  tension  of  the 
ciliary  muscle  probably  aids  by  bringing  on  congestion  of 
the  uveal  tract  (as  it  certainly  appears  to  do  of  the  disk), 
and  thus  predisposes  to  softening  and  yielding  of  the  tunics.; 
to  this  congestion  the  habit  of  stooping  over  the  book  or 
work  contributes  by  retarding  the  return  of  blood.  It  is 
evident  that  if  the  disease  be  once  started  by  such  causes, 
they  will  tend  powerfully  to  increase  it.  Myopia  seldom 
increases  after  the  age  of  twenty-five,  unless  under  special 
circumstances;  but  general  eufeeblement  of  health,  as  after 
severe  illness  or  prolonged  suckling,  seriously  increases  the 


MYOPIA.  295 

risk  of  its  progress.  Any  condition  of  imperfect  sight  in 
childhood  in  which  better  vision  is  gained  by  holding  ob- 
jects very  close  is  likely  to  bring  on  M. ;  and  so  we  find  it 
disproportionately  common  amongst  those  who  from  child- 
hood have  suffered  from  corneal  nebulse,  partial  (especially 
lamellar)  cataract,  severe  choroiditis,  or  a  high  degree  of 
astigmatism. 

THE  TREATMENT  is  divisible  into  (1)  prophylactic  and 
(2)  remedial — 1.  Much  may  be  done  to  prevent  M.,  or  to 
check  its  increase  when  it  has  begun,  by  regulating  the 
light,  books,  and  desks  used  by  children,  so  as  to  remove 
the  temptations  to  stooping.  Children  should  not  be 
allowed  to  read  or  work  by  flickering  or  dull  light;  and  as 
we  write  and  read  from  L.  to  B,.,  it  is  best,  whenever  pos- 
sible, to  sit  so  that  the  light  comes  from  the  left,  and  throws 
the  shadow  of  the  pen  towards  the  right  and  away  from 
the  object  looked  at.  A  myopic  child  should  not  be  allowed 
to  fully  indulge  his  bent,  which  is  generally  strong,  for  ex- 
cessive reading.  2.  By  means  of  suitable  glasses  (a)  distant 
objects  may  be  seen  clearly,  i.  e.,  the  eye  be  rendered  em- 
metropic,  (i)  reading  and  working  become  possible  at  a 
greater  distance.  The  strain  on  the  internal  recti  usually 
ceases  when  the  gaze  is  directed  into  the  distance,  whether 
vision  be  distinct  or  not;  glasses  for  distant  vision  have 
therefore  no  effect  on  the  progress  of  the  myopia ;  they  are 
of  value  only  for  educational  purposes,  that  the  patient 
may  see  what  is  about  him  as  clearly  as  other  people; 
their  use  is  therefore  to  a  great  extent  optional.  But  if 
we  can  somewhat  increase  the  distance  of  the  natural  far 
point  (r)  from  the  eyes,  we  lessen  the  tension  on  the  in- 
ternal recti  in  near  vision,  diminish  the  temptations  to 
stooping  and  to  reading  by  bad  light,  and  so  help  to  check 
the  progress  of  the  disease;  hence  glasses  for  near  work 
are  very  important  in  the  higher  degrees  of  myopia  (from 
3  D.  upwards)  in  early  life.  When  the  M.  has  been  sta- 


296       REFRACTION     AND     ACCOMMODATION. 

tionary  for  years,  however,  we  may  generally  leave  the 
decision  even  of  this  point  to  the  patient's  own  choice. 

Before  ordering  glasses    for   either   purpose    we   must 
measure  accurately  the  degree  of  M.     In  Fig.  94  let  r  be 


FIG.  94. 


Myopia  corrected  by  concave  lens. 

the  far  point,  and  let  it  be  25  cm.  in  front  of  the  patient's 
eye,  so  that  he  can  see  nothing  clearly  at  a  greater  distance 
than  25  cm.  (a)  He  is  required  to  see  distant  objects 
(objects  seen  under  approximately  parallel  rays)  clearly. 
A  concave  lens  is  interposed  of  strength  sufficient  to  give 
to  parallel  rays  a  degree  of  divergence,  as  if  they  came 
from  r  (see  Fig.  10).  The  focal  length  of  this  lens  will  be 
the  same  as  its  distance  from  r ;  and,  as  it  is  placed  close 
to  the  eye,  its  focal  length  will  be  very  nearly  the  same  as 
(a  little  shorter  than)  the  patient's  far  point.  Therefore, 
if  we  measure  the  distance  of  r  from  the  patient's  eye,  a 
lens  of  nearly  the  same  focal  length  will  fully  neutralize 
his  myopia.  The  patient  will  choose  a  lens  rather  higher 
than  this  test  would  lead  us  to  expect  if  the  M.  be  uncom- 
plicated ;*  whilst  if,  owing  to  complications,  there  be  con- 

1  It  is  sometimes  stated  that  the  glass  chosen  for  distance  is 
rather  weaker  than  is  indicated  by  the  distance  of  r  from  the 
crystalline  lens,  tho  accommodation  causing  an  apparent  increase 
of  M.  This  is  true  only  in  low  degrees  of  M.,  and  not  always 
even  in  them ;  a  large  number  of  the  patients  choose  a  rather 
stronger  lens  than  is  indicated  by  r,  i.  e.,  a  lens  whose  focus  is 
shorter  by  the  distance  between  its  own  central  point  and  the 
optical  centre  of  the  eye. 


MYOPIA.  297 

siderable  defect  of  vision,  he  will  often  choose  a  somewhat 
lower  glass.  Hence  it  is  a  good  rule  to  begin  the  trial  with 
a  lens  much  weaker  than  the  one  which,  judging  by  the 
above  test,  we  expect  the  patient  to  choose,  and  to  try 
successively  stronger  ones  till  the  best  result  is  reached. 
The  weakest  concave  glass  which  gives  the  best  attainable 
sight  for  the  distant  test-types  (p.  43)  is  the  measure  of  the 
M.,  and  this  glass,  but  not  a  stronger  one,  may  be  safely 
worn  for  distant  vision.  Beginners  often  test  M.  patients 
with  concave  glasses  for  near  types.  Neither  -f-  nor  - 
glasses  give  any  information  about  the  refraction  when  used 
for  near  objects,  since  they  merely  either  substitute  or  call 
into  use  the  accommodation. 

(6)  A  glass  is  needed  with  which  the  patient  will  be 
able  to  read  or  sew  at  a  distance  greater  than  his  natural 
far  point.  Theoretically  the  fully  correcting  glass  (a) 
would  suit,  since  it  gives  to  all  rays  a  course  which,  in 
relation  to  the  myopic  eye,  is  the  same  as  that  of  the  rays 
entering  a  normal  eye.  But  this  glass  cannot  safely  be 
allowed  in  the  higher  degrees  of  M.  The  lens  which  fully 
corrects  the  myopia  diminishes  the  size  of  the  retinal 
images  so  much  that  the  patient  is  tempted  to  enlarge 
them  again  by  approaching  the  object  nearer;  again,  the 
accommodation  is  often  defective  in  the  higher  degrees  of 
M.,  and,  as  the  fully  correcting  lens  requires  full  accom- 
modation, it  will  lead  to  over-straining  if  the  function  be 
weakened,  and  so  cause  discomfort  if  nothing  worse.  For 
these  two  reasons  the  rule  is  to  give,  for  near  work,  a  glass 
which  will  diminish  the  myopia,  but  not  fully  correct  it. 

Let  M.  be  7  D.,  then  r  will  be  at  14  cm.  (p.  28)  from  the 
eye.  Let  a  glass  be  required  with  which  the  patient  shall 
be  able  to  read  at  30  cm.,  or  which  shall  remove  r  from 
14  cm.  to  30  cm.,  i.  e.,  shall  leave  the  patient  with  M.  3  D. 
We  must,  therefore,  correct  the  difference  between  7  D. 
and  3  D.  (7 — 4  =  3  D.)  ;  and  a  concave  lens  of  4  D.  will 


298       ItEFRACTION     AND    ACCOMMODATION. 

make  rays  from  30  cm.  diverge  as  if  they  came  from  14  cm. 
But  even  this  partial  correction  may  diminish  the  images 
so  much  that,  if  vision  be  imperfect,  from  extensive 
choroidal  changes,  reading  at  the  increased  distance  will 
be  so  difficult  that  the  patient  will  prefer  to  bring  the 
object  nearer  again  at  the  expense  of  accommodation,  and 
will  thus  be  inconvenienced  instead  of  bettered  ;  it  is, 
therefore,  often  advisable,  even  for  partial  correction,  to 
order  a  weaker  lens  than  is  optically  correct 

Aching  from  preponderance  of  the  external  over  the  in- 
ternal recti  (insufficiency  of  the  internal  recti,  p.  290),  if 
not  cured  by  partially  correcting  glasses,  is  often  best 
treated  by  division  of  the  external  rectus  of  one  or  both 
eyes.  This  operation  may  always  be  done  when  there  is  a 
marked  divergent  squint  even  if  the  squint  be  variable. 
Prismatic  spectacles  (p.  22),  the  bases  of  the  prisms  being 
towards  the  nose,  are  very  serviceable  for  reading,  in  some 
cases  of  muscular  insufficiency.  By  deflecting  the  enter- 
ing light  towards  their  bases  (Fig.  15)  the  prisms  give  to 
rays  from  a  certain  near  point  a  direction  as  if  they  came 
from  a  greater  distance,  and  thus  lessen  the  need  for  con- 
vergence of  the  optic  axes.  The  prisms  may  be  combined 
Avith  concave  lenses. 

Myopia  may  also  be  caused  by  an  increase  of  the  curva- 
ture, or  of  the  refractive  power  of  the  media  (inyopia  of 
curvature).  Thus,  in  conical  cornea  (p.  124)  the  curvature 
of  the  central  part  of  the  cornea  is  increased  (i.  e.,  its  focal 
length  shortened),  and  the  principal  focus  of  the  lens-sys- 
tem lies  in  front  of  the  retina,  often  very  far  in  front.  In 
commencing  senile  cataract  (p.  175)  M.  is  sometimes  caused 
by  shortening  of  the  focal  length  of  the  crystalline  lens, 
but  whether  by  increase  of  its  convexity,  or  of  its  refrac- 
tive index  (p.  13)  is  uncertain.  In  some  diseases  the  refrac- 
tive index  of  the  vitreous  is  increased  with  the  same  result 
for  a  time.  M.  is  sometimes  simulated  in  H.,  and  actual 


HYPERMETROPIA.  299 

M.  increased  by  needless  and  uncontrollable  action  of  the 
ciliary  muscle. 

HYPERMETROPIA.    (H.) 

Hypermetropia  is  optically  the  reverse  of  myopia.  It  is 
one  of  the  commonest  conditions  we  have  to  treat.  The 
eyeball  is  too  short  (axial  hypermetropia^,  so  that  when  the 
accommodation  is  relaxed  the  retina  lies  within  the  princi- 
pal focus  of  the  eye.  As  rays  from  an  object  within  the 
principal  focus  of  a  convex  lens  emerge  from  the  lens 
divergent  (Figs.  9  and  12),  so  pencils  of  rays  leaving  a 
hypermetropic  eye  are  divergent  (Fig.  97) ;  and  conversely, 
only  rays  already  convergent  can  be  focussed  on  the  retina. 
H.  always  dates  from  birth  and  does  not  afterwards  in- 
crease, except  slightly,  in  old  age.  But  it  may  diminish 
and  even  give  place  to  M.  by  elongation  of  the  eye.  In 
Fig.  95  the  curved  line  representing  the  retina  is  in  front  of 

FIG.  95. 


Hypermetropia. — Parallel   rays  focussed  behind   retina.     Kays  already 
convergent  focussed  on  retina. 

F  (compare  Fig.  87).  Parallel  rays  will,  after  passing 
through  the  lens,  meet  the  retina  before  focussing  and  form 
a  blurred  image,  whilst  divergent  rays,  meeting  the  retina 
still  further  from  their  focus,  will  form  an  even  worse 
image  (compare  Fig.  88);  hence  neither  distant  nor  near 
objects  will  be  seen  clearly.  But  by  using  accommodation 
the  focal  length  can  be  shortened  until  the  focus  falls  upon 
the  retina  (Fig.  96),  and  distant  objects  are  then  seen 


300       REFRACTION    AND    ACCOMMODATION. 

clearly ;  and  additional  accommodation  will  give  also  dis- 
tinct vision  of  near  objects  (compare  Fig.  89).  A  little 
consideration  will  show  that  the  competence  of  the  ciliary 
muscle  to  give  these  results  will  depend  in  any  given  case: 
(1)  on  the  degree  of  advancement  of  the  retina  in  front  of 


Ilypermetropia  corrected  hy  accommodation.     Parallel  rays  focussed  ru 

retina. 

F,  i.  e.,  on  the  degree  of  shortening  of  the  eye ;  and  (2)  on 
the  strength  of  A.,  i.  e.,  on  the  extent  to  which  the  focal 
length  of  the  lens  can  be  shortened. 

Fig.  97  may  be  taken  for  a  section  of  a  very  highly 
hypermetropic  eye,  the  rays   emerging  from   which  are 

FIG.  97. 


Course  of  the  rays  emerging  from  a  hypermetropic  eye. 


divergent.  The  image  formed  on  the  retina  of  a  hyper- 
metropic eye  is  smaller  than  that  of  the  same  object  placed 
at  the  same  distance  from  a  normal  eye  (p.  25,  §  19). 

In  old  age  the  crystalline  lens  becomes  flatter  and  less 
refractive,  and,  therefore,  an  eye  originally  emmetropic  is 
now  unable  to  focus  parallel  rays  on  the  retina ;  this  con- 


HYPERMETROPIA.  301 

dition  causes  slight  acquired  hypennetropia,  and  begins  at 
the  age  of  sixty-five. 

SYMPTOMS  AND  RESULTS  OF  H. — The  direct  symptoms 
are  due  to  insufficiency  of  the  accommodation;  for  distinct 
vision  of  any  object,  whether  near  or  distant,  requires  A. 
proportionate  to  the  degree  of  shortening  of  the  eye,  and 
the  absolute  power  (amplitude)  of  A.  is  not  increased,  at 
any  rate  not  enough  to  meet  the  demand.  In  a  given  case, 
A.  being  relaxed,  let  the  rays  on  leaving  the  eye  diverge, 
as  if  they  proceeded  from  a  point,  the  virtual  focus  of  the 
retina  (compare  Fig.  12),  10  cm.  behind  it,  i.  e.,  25  cm. 
behind  the  crystalline  lens  (p.  25,  §  19).  If  parallel  rays 
pass  through,  a  convex  lens  of  25  cm.  focal  length  held 
close  to  the  eye,  they  will  be  made  to  converge  towards 
this  same  point,  and  therefore  in  accordance  with  §  12 
(p.  18)  will  be  focussed  on  the  retina.  The  same  end  can 
be  equally  gained  by  using  A.,  so  as  to  shorten  the  focus 
of  the  crystalline  lens  to  a  corresponding  extent. 

If  H.  is  slight  or  moderate  and  A.  vigorous,  no  incon- 
venience is  felt  either  for  near  or  distant  vision.  But  if  A. 
have  been  weakened  by  disease  or  ill-health,  or  have  failed 
with  age,  the  patient  will  complain  that  he  can  no  longer 
see  near  objects  clearly  for  long  together;  that  the  eyes 
ache  or  water,  or  that  everything  "swims"  or  becomes 
"  dim,"  after  reading  or  sewing  for  a  short  time  (accommo- 
dative asthenopia,  see  also  p.  244).  There  is  not  usually 
much  complaint  of  defect  for  distant  objects.  Many  slight 
or  moderately  H.  patients  find  no  inconvenience  till  25  or 
30  years  of  age,  when  A.  has  naturally  declined  by  nearly 
one-half  (p.  315).  Women  are  often  first  troubled  after  a 
long  lactation,  and  men  when  they  have  had  to  work  hard 
for  examinations  or  in  the  office,  or  are  suffering  from 
chronic  exhausting  diseases.  In  children  the  complaint  is 
often  of  watering,  blinking,  and  headache,  rather  than  of 
dimness. 

26 


302       REFRACTION    AND    ACCOMMODATION. 

In  very  high  degrees  of  H.  a  large  part  of  the  accommo- 
dation is  always  needed  from  childhood  upwards  for  distant 
sight;  and  even  the  strongest  effort  does  not  suffice  to  give 
good  vision  of  near  objects,  which  consequently  such  a 
person  never  sees  clearly.  Such  patients  often  partly 
compensate  for  the  dimness  of  near  objects  by  bringing 
them  still  nearer,  thus  enlarging  the  visual  angle  and  in- 
creasing the  size  of  the  retinal  images  (p.  26).  This  symp- 
tom may  be  mistaken  for  myopia,  but  can  be  distinguished 
by  the  want  of  uniformity  in  the  distance  at  which  the 
patient  places  his  book,  and  by  his  being  often  unable,  at 
any  distance  whatever,  to  see  the  print  easily  or  to  read 
fluently.  In  the  highest  degrees  even  distinct  distant  vision 
is  not  constantly  maintained,  the  patient  often  being  con- 
tent to  let  his  accommodation  rest,  except  when  his  atten- 
tion is  roused. 

As  age  advances,  a  point  is  reached,  even  in  moderate 
degrees  of  H.,  at  which  A.  no  longer  suffices  even  for  dis- 
tant, and  much  less  for  near,  vision.  Such  persons  tell  us 
that  they  took  to  glasses  for  near  work  comparatively  early, 
but  add  that  lately  the  glasses  have  not  suited,  and  that 
they  are  now  unable  to  see  clearly  either  at  long  or  short 
distances.  Ophthalmoscopic  examination  shows  no  change 
except  H.,  and  suitable  convex  glasses  at  once  raise  distant 
vision  to  the  normal.  Occasionally  photophobia,  slight 
cohjunctival  irritation,  and  redness  are  present  in  H.,  but 
the  first-named  symptom  is  less  common  than  in  myopia. 
(See  also  p.  244.) 

The  most  important  indirect  result  of  H.  is  convergent 
strabismus.  To  understand  this  we  must  remember  that 
there  is  a  certain  constant  relation  between  the  action  of 
the  ciliary  muscles  and  of  the  internal  recti,  that  the  ac- 
commodation can  be  exerted  only  to  a  very  limited  degree 
without  convergence  of  the  optic  axes,  and  that  for  every 
degree  of  accommodation  there  is  in  the  normal  state  a 


HYPEllMETROl'IA.  303 

constant  amount  of  convergence  (compare  p.  44).  In  H. 
accurate  near  sight  needs,  as  we  have  seen,  an  excess  of  A., 
thus,  e.  ff.,  with  H.  of  2  D.,  clear  vision  of  an  object  at 
50  cm.  will  require  as  much  A.  as  vision  at  25  cm.  by  a 
normal  eye,  and  this  A.  cannot  be  exerted  without  con- 
verging for  25  cm.  (or  nearly  so).  Such  a  person,  there- 
fore, has  to  do  two  things  at  once — to  look  at  an  object 
distant  50  cm.,  and  to  make  his  optic  axes  meet  at  25  cm. 
The  former  he  does  by  directing  one  eye  (e.  g.,  the  R.)  to 
the  object  50  cm.  off;  the  latter  by  directing  the  visual 
axis  of  the  L.  eye  so  as  to  meet  that  of  the  R.  at  25  cm., 
instead  of  50  cm.  In  this  case  the  L.  eye  will  squint  in- 
wards, but  both  internal  recti  will  act  equally  in  bringing 
the  squint  about,  and  both  eyes  will  use  as  much  A.  as  a 
pair  of  normal  eyes  would  do  at  25  cm. 

This  "concomitant"  convergent  strabismus  (p.  32,  §  4) 
generally  comes  on  early  in  childhood,  as  soon  as  the  child 
begins  to  look  attentively  and  use  its  accommodation  vigor- 
ously in  regarding  near  objects.  In  examining  cases  we 
shall  be  struck  by  finding  that:  (1)  in  some  the  squint  is 
noticed  only  when  A.  is  in  full  use,  that  it  appears  and  dis- 
appears under  observation  according  as  the  child  fixes  its 
gaze  on  a  near  object  or  looks  into  space  (periodic  squint)} 
(2)  in  others  the  squint  is  constant,  but  is  more  marked 
during  strong  A. ;  (3)  it  is  constant,  invariable,  and  of 
high  degree ;  (4)  in  most  cases  the  squint  always  affects 
the  same  eye,  and  this  is  generally  accounted  for  by  some 
original  defect  of  the  eye  itself  (such  as  a  higher  degree  of 
H.,  or  As.,  or  a  cornea!  opacity),  which  leads  to  its  fellow 
being  chosen  for  distinct  sight ;  but  patients  who  see  equally 
well  with  each  eye  often  squint  with  either  indifferently 
(alternating  squint).  The  squint  causes  diplopia  (homony- 
mous,  p.  320),  and  to  avoid  this  inconvenience,  patients  for 
the  most  part  soon  learn  to  ignore  (or  "suppress")  the 
image  formed  in  the  squinting  eye,  the  result  usually  being 


304       REFRACTION    AND    ACCOMMODATION. 

that  this  eye  becomes  very  defective.  This  power  of  sup- 
pressing the  false  image  is  learnt  most  easily  in  very  early 
life.  In  alternating  squint  no  permanent  suppression 
occurs,  and  consequently  both  eyes  remain  good  (p.  238). 

It  will  soon  be  noticed  that  squint  is  not  present  in  every 
case  of  H.  In  very  low  degrees  the  necessary  extra  ac- 
commodation can  be  used  without  any  extra  convergence 
(relative  accommodation,  p.  44).  In  very  high  degrees,  on 
the  other  hand,  the  effort  needed  for  distinct  vision,  even 
of  distant,  and  a  fortiori  of  near,  objects,  is  so  great,  that 
the  child  often  sacrifices  distinctness  to  comfort  and  bin- 
ocular vision,  using  only  so  much  accommodation  as  can 
be  employed  without  over-convergence.  The  squint  not 
uncommonly  disappears  spontaneously  as  the  child  grows 
up,  a  fact,  perhaps,  explained  by  an  increased  power  of 
dissociating  A.  from  convergence,  or,  perhaps,  by  a  diminu- 
tion of  H.  from  elongation  of  the  eye. 

THE  TREATMENT  of  H.  consists  in  removing  the  neces- 
sity for  overuse  of  A.  by  prescribing  convex  spectacles 
which,  in  proportion  to  their  strength,  supply  the  place  of 
the  increased  convexity  of  the  crystalline  lens  induced  by 
A.  In  theory,  the  whole  H.  ought  to  be  corrected  by 
glasses  in  every  case,  and  the  eye  be  rendered  emmetropic. 
But  in  practice  we  find  it  often  better  to  give  a  weaker 
glass,  at  least  for  a  time. 

If  A.  in  a  H.  eye  be  in  abeyance  (paralyzed  by  atropia), 
vision  for  distant  objects  will  be  distinct  only  if  the  rays 
pass  through  a  convex  lens,  held  in  front  of  the  eye,  whose 
focus  coincides  with  the  virtual  focus  of  the  retina  (p.  301). 
The  strength  of  this  lens  is  the  measure  of  the  H. ;  thus  the 
patient  has  H.  2  D.  if  a  convex  lens  of  50  cm.  focal  length 
is  necessary  for  this  purpose. 

But  if  A.  be  intact,  as  the  patient  has  constantly  to  use 
it  for  distant  sight,  he  is  often  unable  to  relax  it  fully, 
when  a  corresponding  convex  lens  is  placed  in  front  of  the 


HYPERMETROPIA.  305 

eye ;  he  will  relax  only  a  part,  and  this  part  will  be  meas- 
ured by  the  strongest  convex  lens  with  which  he  can  see 
the  distant  types  clearly.  That  part  of  the  H.  which  can 
be  detected  by  this  test  is  called  "  manifest "  (H.  m.).  The 
part  remaining  undetected,  because  corrected  by  the  in- 
voluntary use  of  A.,  is  latent  (H.  1. ).  The  sum  of  the 
H.  m.  and  H.  1.  is  the  total  (H.). 

Now,  most  H.  people  can  habitually  use  some  A.  for  dis- 
tance (and  a  corresponding  excess  for  near  vision)  without 
inconvenience,  and  hence  the  full  correction  of  H.  is  by  no 
means  always  needful,  or  even  agreeable  to  the  patient. 
In  many  cases  the  correction  of  the  H.  m.  is  enough  to  re- 
lieve the  astheuopic  symptoms,  at  any  rate,  for  a  consider- 
able time;  but  we  often  find  that  after  wearing  these 
glasses  for  some  weeks  or  months  the  symptoms  return, 
and  a  fresh  trial  will  then  show  a  larger  amount  of  H.  m., 
which  must  then  again  be  corrected  by  a  corresponding  in- 
crease in  the  strength  of  the  glasses.  This  process  may 
have  to  be  repeated  several  times  until  after  a  few  months 
the  total  H.  becomes  manifest,  and  may  be  corrected. 
This  method  is  most  suitable  for  adults  in  whom  the  use  of 
atropine  for  paralyzing  A.,  and  allowing  the  immediate 
estimation  of  the  total  H.,  is  inconvenient  or  impossible ; 
or  for  whom  the  glasses  which  correct  the  total  H.,  as  es- 
timated by  the  ophthalmoscope,  without  atropization,  are 
found,  if  ordered  at  once,  to  be  inconveniently  strong.  But 
for  children  there  is  seldom  any  gain  and  often  no  little 
inconvenience  from  following  this  gradual  plan  ;  with  them 
the  better  way  is  to  estimate  the  total  H.,  and  to  order 
glasses  slightly  (1  D.)  weaker  than  that  amount. 

To  EXAMINE  FOR  H. — (1)  For  H.  m.  Note  the  patient's 
vision  for  distant  types  at  6  m.,  then  hold  in  front  of  his 
eyes  a  very  weak  convex  lens  (+5  D.),  and  if  he  sees  as 
well,  or  better,  Avith  it,  go  to  the  next  stronger  lens,  and  so 
on  until  the  strongest  has  been  found  which  allows  the  best 

26* 


306       REFRACTION     AND     ACCOMMODATION. 

attainable  distant  vision ;  this  lens  is  the  measure  of  the 
H.  m. 

(2)  For  H.  (total). — The  easiest  and  most  certain  plan 
is  to  direct  the  patient  to  use  strong  atropine  drops  (F.  24) 
three  times  a  day  for  at  least  two  days,  and  then  to  test  his 
distant  vision  with  convex  glasses.  As  in  (1),  the  strongest 
lens  which  gives  the  best  attainable  sight  is  the  measure  of 
the  H. 

OPHTHALMOSCOPIC  TESTS. — (3)  The  image  of  the  disk 
seen  by  the  indirect  method  becomes  smaller  when  the  lens 
is  withdrawn  from  the  eye  (compare  p.  291,  2). 

(4)  The  retinoscopic  test  is  described  at  p.  78. 

(5)  By  direct  examination  an  erect  image  is  seen  at 
whatever  distance  the  observer  be  from  the  patient  (p.  75). 
If  the  observer  be  skilled  enough  he  may,  as  stated  at  p.  75, 
estimate  H.  with  almost  as  great  accuracy  with  a  refraction 
ophthalmoscope  as  by  trial  lenses,  and  this  plan  is  often 
almost  indispensable  with  children  who  are  too  young  or 
too  backward  to  give  good  answers.     The  total,  or  nearly 
the  total,  H.  may  be  found  in  this  way  without  atropine  if 
the  examination  be  made  in  a  dark  room,  for  then  A.  is 
generally  quite  relaxed,  however  persistently  it  may  have 
acted  when  the  patient  was  able  to  look  attentively  at 
objects  in  the  light.    But  it  is  often  better  in  practice  to  use 
atropine  before  making  this  estimation. 

The  next  question  is,  whether  the  glasses  are  to  be  worn 
always,  or  only  when  the  accommodation  is  specially 
strained,  i.  e.,  in  near  work.  They  are  to  be  worn  con- 
stantly (1)  whenever  we  are  attempting  to  cure  a  squint  by 
their  means ;  (2)  in  all  cases  of  high  H.  in  children,  whether 
with  or  without  strabismus.  But  patients  who  come  under 
care  for  the  first  time  as  young  adults,  in  whom  the  H.  is, 
as  a  rule,  of  moderate  or  low  degree,  may  generally  be 
allowed  to  wear  them  only  for  near  work.  Elderly  per- 
sons require  two  pairs — one  for  distance,  neutralizing  the 


HYPERMETKOPIA.  307 

H.  m.,  the  other  stronger,  neutralizing  the  presbyopia  also, 
for  near  work  (p.  315) ;  the  use  of  the  former  may,  how- 
ever, be  left  to  the  patient's  discretion. 

Treatment  of  Convergent  Hypermetropic  Squint. 

(1)  If  the  squint  be  periodic  (p.  303),  it  can  be  cured 
by  the  constant  use  of  the  spectacles  which  correct  the 
total  H. 

(2)  The  same  is  true  in  some  cases  where  the  squint, 
though  constant,  varies  in  degree,  being  greater  during 
accommodation  for  near  than  for  distant  objects.     It  is 
best  to  use  atropine  in  all  such  cases,  and  if  under  its  use 
the  squint  disappear,  or  be  much  lessened,  glasses  will  cure 
it.*  "VVe  shall,  however,  often  be  disappointed  to  find  the 
squint  as  marked  as  ever,  even  with  complete  paralysis  of 
accommodation,  and  then,  as  a  rule,  it  is  not  curable  by 
glasses. 

(3)  If  the  squint  be  constant  in  amount  and  of  some 
years'  standing,  operation  is  usually  necessary.     As  the 
squinting  eye  is  in  such  usually  very  defective  (p.  303), 
the  removal  of  the  deformity  is  the  chief  object  of  the 
operation,  binocular  vision  being   comparatively   seldom 
restored.     Hence,  in  view  of  the  tendency  to  spontaneous 
cure  already  mentioned,  it  is  better  not  to  operate  on  very 
young  children,  especially  as  in  them  we  cannot  easily  tell 
whether   or   not   the   squint   is  still  periodic.     The  most 
rational  treatment  for  children  under  4  (when  glasses  may 
often  be  begun)  is  to  cover  the  eyes  alternately  with  a 
blind  for  some  hours  daily,  to  ensure  each  eye  being  alter- 
nately used  (p.  238) ;  but  naturally  this  is  seldom  carried 
out.     When  operation  is  decided  upon  it  is  a  safe  rule  to 
divide  only  one  internal  rectus  at  a  sitting.    At  the  end  of  a 
few  weeks,  if  the  squint  still  be  considerable,  the  operation 
is  performed  on  the  other  eye.    Muscular  asthenopia  is  very 


308       REFRACTION    AND    ACCOMMODATION. 

likely  to  come  on  some  years  later  if  both  tendons  are 
needlessly  divided.  It  is  safer  to  leave  slight  convergence 
than  to  run  this  risk.  (See  also  Divergent  Strabismus.) 

ASTIGMATISM.   (As.) 

In  the  preceding  cases  (M.  and  H.)  the  refracting  sur- 
faces of  the  eye  (the  front  of  the  cornea  and  the  two  surfaces 
of  the  lens)  have  been  regarded  as  segments  of  spheres. 

All  the  rays  of  a  cone  of  light  which  issue  from  a  round 
spot  and  pass  through  such  a  system  are  (neglecting 
"spherical  aberration")  equally  refracted,  and  meet  one 
another  at  a  single  point — the  focus  of  the  system.  For  if 
such  a  cone  of  incident  light  be  looked  upon  as  composed 
of  a  number  of  different  planes  of  rays  situated  radially 
around  the  axis  of  the  cone,  the  rays  situated  in  any  plane 
(say  the  vertical)  will,  after  passing  through  the  lens- 
system,  meet  behind  it  at  its  focus,  whilst  those  forming 
any  other  plane  (as  the  horizontal)  will  meet  at  the  same 
point;  and  the  same  will  be  true  of  all  the  intermediate 
planes. 

But  let  the  curvature,  and  therefore  the  refractive  power, 
of  one  of  the  media  (for  instance,  the  cornea)  be  greater  in 
one  meridian,  say  the  vertical,  than  in  the  horizontal,  then 
the  vertical-plane  rays  will  meet  at  their  focus,  whilst  the 
horizontal-plane  rays  at  the  same  distance  will  not  yet  have 
met,  and  if  received  on  a  screen  will  form  a  horizontal  line 
of  light.  If  the  intermediate  meridians  had  regularly  in- 
termediate focal  lengths  they  would  form,  at  the  same  place, 
lines  of  intermediate  lengths,  and  the  image  of  the  round 
spot  of  light,  if  caught  on  a  screen  at  this  distance,  would 
form  a  horizontal  oval.  To  a  retina  receiving  such  an 
image  the  round  point  of  light  would  appear  drawn  out 
horizontally.  Such  an  eye  is  called  astigmatic,  because 


ASTIGMATISM.  309 

unable  to  see  a  point  as  such,  all  points  appearing  drawn 
out  more  or  less  into  lines. 

A  little  reflection  will  show  that  in  the  same  case,  at  the 
focal  point  of  the  horizontal-plane  rays,  the  rays  of  the 
vertical  plane  will  already  have  met  and  crossed,  and  that 
the  image  at  this  point  will  form  a  vertical  oval. 

If  the  screen  be  placed  midway  between  these  two  ex- 
treme points,  the  image  will  be  circular  but  blurred,  because 
the  vertical-plane  rays  will  have  crossed,  and  begun  to 
separate,  while  the  horizontal  ones  will  not  yet  have  met, 
and  each  set  will  be  equally  distant  from  its  focus.  The 
meridians  of  the  astigmatic  medium  which  refract  most 
(shortest  focus)  and  least  (longest  focus)  are  the  "principal 
meridians"  The  distance  between  their  foci  is  the  "focal 
interval"  and  represents  the  degree  of  astigmatism. 

The  astigmatism  of  the  eye  may  be  regular  or  irregular. 
In  regular  astigmatism  the  meridians  of  greatest  and  least 
refractive  power,  "  principal  meridians,"  are  always  at  right 
angles  to  each  other ;  the  intermediate  meridians  are  of  reg- 
ularly intermediate  focal  lengths;  and  every  meridian  is 
nearly  a  segment  of  a  circle.  Of  the  principal  meridians 
the  most  refractive  (the  one  with  shortest  focal  length)  is, 
as  a  rule,  vertical  or  nearly  so,  and  the  least  refractive, 
therefore,  horizontal  or  nearly  so.  The  cornea  is  the  princi- 
pal seat  of  this  asymmetry,  but  the  crystalline  lens  is  also 
astigmatic,  to  a  less  degree,  and  its  meridians  of  greatest 
and  least  curvature  are  usually  so  arranged  as  in  some  de- 
gree to  neutralize  those  of  the  cornea,  so  that  it  partially 
corrects  the  corneal  error. 

Regular  astigmatism  is  remedied  by  supplying  a  lens 
which  equalizes  the  refraction  in  the  two  principal  me- 
ridians. Such  a  lens  must  be  a  segment  of  a  cylinder  instead 
of,  like  an  ordinary  lens,  a  segment  of  a  sphere.  Rays 
traversing  a  cylindrical  lens  in  the  plane  of  the  axis  of  the 
cylinder  are  not  refracted,  since  the  surfaces  of  the  lens  in 


310       REFKACTION     AND    ACCOMMODATION. 

this  direction  are  parallel ;  but  rays  traversing  it  in  all 
other  planes  are  refracted  more  or  less,  and  most  in  the 
plane  or  meridian  at  a  right  angle  with  the  axis. 

Irregular  astigmatism  may  be  caused  either  by  irregu- 
larities of  the  cornea,  arising  from  ulceration  or  conical 
cornea  (p.  124)  ;  or  by  various  conditions  of  the  crystalline 
lens,  such  as  differences  of  refraction  in  its  various  sectors, 
tilting  or  lateral  dislocation  of  the  entire  lens,  so  that  its 
axis  no  longer  corresponds,  as  it  should  do,  with  the  centre 
of  the  cornea.  Irregular  astigmatism  causes  much  distor- 
tion of  the  ophthalmoscopic  image,  especially  when  the 
lens  is  moved  from  side  to  side.  It  is  seldom  much  bene- 
fited by  glasses. 

Returning  to  regular  astigmatism,  it  will  be  seen  that  the 
optical  condition  of  the  eye  depends  upon  the  position  of 
the  retina  in  respect  to  the  focal  interval.  In  the  following 
diagram  (Fig.  98)  let  the  most  refracting  meridian  be 
vertical  and  its  focus  be  called  a,  the  least  refracting 

FIG.  98. 


meridian  horizontal  and  its  focus,  b.  (The  astigmatism  is 
here  represented  as  caused  by  altered  position  of  the  retina 
in  different  planes,  instead  of  by  altered  curvature  of  the 
cornea  in  different  planes;  and  the  diagram  is,  of  course, 
only  intended  to  aid  the  comprehension  of  the  principle.) 
(1)  Let  a  fall  on  the  retina  (1,  Fig.  98),  and  b,  therefore, 
behind  it.  There  is  E.  in  the  vertical  meridian,  and  there- 
fore H.  in  the  horizontal  meridian ;  this  is  simple  hyper- 


ASTIGMATISM.  311 

metropic  astigmatism.  (2)  Let  6  fall  on  the  retina  (2, 
Fig.  98),  and  a  in  front  of  it.  The  horizontal  meridian  is, 
therefore,  E.,  and  the  vertical  meridian  M. ;  simple  myopic 
astigmatism.  (3)  Let  a  and  b  both  lie  behind  the  retina 
(3,  Fig.  98).  There  is  H.  in  both  meridians,  but  more  in 
the  horizontal  than  the  vertical  meridian ;  compound  hyper- 
metropic  astigmatism.  (4)  a  and  b  are  both  in  front  of 
the  retina  (4,  Fig.  98).  There  is  M.  in  both  meridians, 
but  more  in  the  vertical  than  the  horizontal;  compound 
myopic  astigmatism.  (5)  a  is  in  front  of  the  retina,  and 
b  behind  it  (5,  Fig.  98).  There  is  M.  in  the  vertical  and 
H.  in  the  horizontal  meridian  ;  mixed  astigmatism. 

The  general  symptoms  of  astigmatism  «».re  of  the  same 
order  as  those  caused  by  the  simpler  defects  of  refraction, 
but  attention  to  the  patient's  complaints,  and  observation 
of  the  manner  in  which  he  uses  his  eyes  will  in  the  higher 
degrees  often  give  the  clue  to  its  presence.  Low  degrees, 
especially  of  simple  hypermetropic  astigmatism,  often  give 
rise  to  no  inconvenience  till  rather  late  in  life.  As.  is  most 
commonly  met  with  in  connection  with  H.,  because  H.  is 
so  much  commoner  than  M.  But  it  is  said  to  occur  with 
greater  relative  frequency  in  M.,  when  if  complications  be 
present  it  may,  if  not  of  high  degree,  be  readily  overlooked 
unless  especially  sought  for.  The  higher  grades  of  As. 
cause  much  inconvenience,  no  objects  being  seen  clearly ; 
and  ordinary  glasses,  though  of  use  if  the  As.  be  com- 
pound, are  nearly  useless  if  it  be  simple.  As.  is  always  to 
be  suspected  if,  with  the  best  attainable  spherical  glasses, 
distant  vision  is  less  improved  than  it  ought  to  be  (suppos- 
ing, of  course,  that  no  other  changes  are  present  to  account 
for  the  defect).  No  definite  rule  can  be  laid  down  as  to 
the  degree  of  defect  which  should  raise  the  suspicion  of  As. ; 
indeed,  in  the  higher  degrees  of  even  simple  M.  and  H., 
acuteness  of  vision  is  often  below  normal  (pp.  239  and 
294). 


312      REFRACTION    AND    ACCOMMODATION. 

As.  may  be  measured  either  by  trial  with  glasses,  or  by 
ophthalmoscopic  estimation  (p.  76)  of  the  refraction  of  the 
retinal  vessels  in  the  two  chief  meridians.  The  latter  is 
the  more  difficult.  A  comparatively  easy  qualitative  test 
is  found  in  the  apparent  shape  of  the  disk,  which  instead 
of  being  round,  is  more  or  less  oval.  In  the  erect  image 
the  long  axis  of  the  oval  corresponds  to  the  meridian  of 
greatest  refraction,  and  is  therefore,  as  a  rule,  nearly 
vertical  (Fig.  99,  and  p.  309).  As.  may  also  be  detected 


FIG. 


Erect  image  of  disk  in  Astigmatism  with  meridian  of  greatest  retraction 
nearly  vertical  (Wecker  and  Jaeger). 

and  measured  by  retinoscopy,  by  remembering  that  on 
rotating  the  mirror  in  a  given  direction  the  shadow  is  seen 
by  means  of  the  meridian  at  right  angles  to  its  border. 

In  the  inverted  image  (Fig.  100)  the  direction  of  the 
oval  is  at  right  angles  to  the  above,  provided  that  the  ob- 
ject lens  be  nearer  than  its  own  focal  length  to  the  eye. 
Astigmatism  is  suspected  when  in  the  erect  image,  an 
undulating  retinal  vessel  appears  clear  in  some  parts,  and 
indistinct  in  others,  an  appearance  which  may  be  taken  for 


ASTIGMATISM.  313 

retinitis  if  the  examination  be  confined  to  the  erect  image. 
It  may  be  imitated  by  looking  at  a  wavy  line  through  a 
cylindrical  lens. 

In  the  indirect  examination  the  shape  of  the  disk  changes 
on  withdrawing  the  lens  from  the  patient's  eye.  It  will  be 
remembered  that  in  M.  the  image  increases  as  the  lens  is 

FZG.  100. 


The  same  disk,  seen  by  the  indirect  method  (Weoker  and  Jaeger.) 

withdrawn  (p.  291,  2),  that  in  E.  its  size  remains  the  same, 
whilst  in  H.  it  diminishes  (p.  306,  3).  Thus,  in  a  case  of 
simple  myopic  astigmatism  in  the  vertical  meridian,  that 
dimension  of  the  disk  which  is  seen  through  the  vertical 
meridian  will  enlarge  on  distancing  the  lens ;  from  being 
oval  horizontally,  when  the  lens  is  close  to  the  eye,  it  be- 
comes first  round  and  then  oval  vertically  on  withdrawing 
the  lens.  In  the  other  forms  of  As.  the  same  holds  true; 
the  image  enlarges,  either  absolutely  as  in  M.  As.,  or  rela- 
tively as  in  H.  As.,  in  the  direction  of  the  most  refracting 
meridian. 

The  subjective  tests  for  As.  are  very  numerous,  but  all 
depend  on  the  fact,  that  if  an  astigmatic  eye  looks  at  a 
number  of  lines  drawn  in  different  directions,  some  will  be 
seen  more  clearly  than  others.  The  form  of  this  test  is  not 
a  matter  of  great  consequence,  provided  that  the  lines  are 

27 


314      REFRACTION    AND    ACCOMMODATION. 

clear,  not  too  fine,  and  are  easily  visible  with  about  half 
the  normal  V.  at  from  3  m.  to  6  m.  The  forms  resembling 
a  clock-face  with  bold  Roman  figures  at  the  ends  of  the 
radii  are  most  convenient,  and  I  prefer  the  pattern  recom- 
mended by  Mr.  Brudenell  Carter  (see  Appendix)  to  any 
other  that  I  have  used.  On  this  face  are  three  parallel 
black  lines  separated  by  equally  wide  white  spaces,  and 
which  collectively  form  a  "  hand  "  that  can  be  turned  round 
into  the  positions  of  best  and  worst  vision. 

The  easiest  case  for  estimation  is  one  of  simple  H.  As., 
in  which  the  eye  is  under  atropine.  Many  cases  of  simple 
M.  As.  are  quite  as  easy  to  test.  In  a  given  case  let  the 
eye  be  Em.  in  the  vertical  meridian,  and  H.  in  the  hori- 
zontal. With  A.  paralyzed,  rays  refracted  by  the  vertical 
meridian  will  be  accurately  focussed  on  the  retina,  whilst 
the  focus  of  those  refracted  by  the  horizontal  meridian  will 
be  behind  the  retina  (Fig.  98,  1),  and  consequently  form 
on  it  a  blurred  image.  Now  the  rays  which  strike  in  the 
plane  of  the  vertical  meridian  are  those  which  come  from 
the  borders  of  horizontal  lines;  hence  the  patient  under 
consideration  will  see  the  lines  at  a  distance  of  3  m.  to  6  m. 
quite  clearly  when  the  "hand"  is  horizontal,  except  their 
ends,  which  will  be  blurred.  The  rays  which  strike  in  the 
plane  of  the  horizontal  meridian  are  those  which  proceed 
from  the  sides  of  vertical  lines,  and  as  this  meridian  is  hy- 
permetropic  the  lines  in  the  "  hand,"  when  placed  vertically, 
will  be  indistinct,  except  their  ends,  which  will  be  sharply 
defined.  We  now  leave  the  "hand"  vertical,  and  test  the 
refraction  for  the  lines  in  this  position  (i.  e.,  for  the  hori- 
zontal meridian)  in  the  ordinary  way  (p.  304,  2),  and  find, 
e.  g.,  that  with  -f-  2  D.  they  are  seen  most  clearly,  though  not 
-perfectly.  On  substituting  for  the  spherical  glass  -f-  2  D. 
cylinder  with  its  curvature  horizontal  (i.  e.,  its  axis  vertical) 
the  lines  of  the  hand  and  all  the  figures  on  the  clock  will 
be  seen  perfectly :  the  vertical  lines  and  figures  being  seen 


ASTIGMATISM.  315 

through  the  horizontal  meridian  corrected  by  the  cylinder 
lens;  the  horizontal  figures  through  the  unaided  vertical 
meridian,  the  rays  which  pass  through  the  cylinder  in  this 
meridian  not  being  refracted. 

In  a  case  of  simple  M.  As.  in  the  vertical  meridian  the 
lines  of  the  hand  will  be  dull  or  invisible  when  horizontal, 
whilst  when  vertical  they  will  be  clear.  On  trial  a  concave 
cylinder  will  be  found,  which,  with  its  curvature  vertical 
(axis  horizontal),  makes  the  lines  of  the  hand  quite  clear 
when  horizontal,  and  all  the  figures  quite  plain. 

The  cases  of  compound  and  mixed  As.  are  less  easily  de- 
tected and  dealt  with.  It  is  generally  best  first  to  find  in 
the  usual  way  the  spherical  glass  which  gives  the  best  result 
for  the  distant  types ;  and  then,  arming  the  eye  with  this 
glass,  to  test  for  As.,  with  the  clock-face  and  cylindrical 
lenses  as  in  the  simple  cases  described  above. 

We  may  use,  instead  of  a  cylindrical  glass,  a  narrow  slit 
in  around  plate  of  metal,  which  can  be  placed  in  the  direc- 
tion of  either  of  the  chief  meridians,  the  spherical  glass 
being  then  found  with  which  in  each  meridian  the  patient 
sees  best.  One  chief  meridian  may  be  ascertained  by  find- 
ing the  direction  of  the  slit  which  gives  the  best  sight  with 
the  spherical  glass  chosen  in  the  preliminary  examination, 
and  the  other  meridian  by  finding  the  glass  which  gives 
the  best  result  with  the  slit  at  a  right  angle  to  the  former 
direction. 

Another  method  (that  of  Javal)  consists  in  making  the 
patient  highly  myopic  for  the  time  being,  by  means  of  a 
convex  lens  (unless  he  be  myopic  already) ;  then  accurately 
finding  his  far  point  for  the  least  myopic  meridian,  and, 
lastly,  finding  the  concave  cylinder  which  is  needed  to  re- 
duce the  opposite  meridian  to  the  same  refraction.  A  spe- 
cial apparatus  is  needed. 

Whatever  means  be  employed,  the  degree  of  As.  is  ex- 
pressed by  the  difference  between  the  glasses  chosen  for  the 


316       REFRACTION    AND    ACCOMMODATION. 

two  chief  meridians;  or  by  the  cylindrical  lens  which, 
added  to  the  chosen  spherical,  gives  the  best  result  for  the 
lines  or  the  distant  types.  When  cylindrical  glasses  are 
ordered  the  whole  of  the  astigmatism  should  be  corrected. 
It  is  not  usually  necessary  to  correct  astigmatism  of  less 
than  1  D.;  but  exceptions  to  this  rule  are  not  uncommon, 
some  patients  deriving  marked  relief  from  the  correction 
of  lower  grades. 

Vision  is,  however,  often  defective  in  astigmatism,  and 
in  the  high  degrees  we  are  often  obliged  to  be  content  with 
a  very  moderate  improvement  at  the  time  of  examination. 
This  may  probably  be  explained  by  the  retina  never  having 
received  clear  images,  i.  e.,  never  having  been  accurately 
practised  (p.  239) ;  and  the  sight  sometimes  improves  after 
proper  glasses  have  been  worn  for  some  months.  Very 
much  also  depends,  in  the  trial,  on  the  intelligence  of  the 
patient;  some  persons  are  far  more  appreciative  of  slight 
changes  in  the  power  of  the  lens  or  in  the  direction  of  the 
axis  of  the  cylinder  than  others,  and  this  apart  from  the 
absolute  acuteness  of  sight. 

Unequal  refraction  in  the  two  eyes  (An-iso-metropia). — 
It  is  common  to  find  a  difference  between  the  two  eyes,  one 
having  more  H.,  more  M.,  or  more  As.  than  its  fellow;  or 
one  being  normal,  while  the  other  is  ametropic.  When  the 
difference  is  not  more  than  is  represented  by  1.5  D.,  and 
V.  is  good  in  both  (see.  p.  239),  the  refraction  may  with 
advantage  be  equalized  by  giving  a  different  glass  to  each 
eye,  and  divergent  squint  from  muscular  asthenopia  may 
sometimes  be  prevented  by  the  increased  stimulus  to  bin- 
ocular vision  thus  given.  But  equalization  is  seldom  pos- 
sible if  the  difference  be  greater,  though,  especially  in 
myopic  cases,  advantage  is  sometimes  gained  by  partial 
equalization.  When  no  attempt  is  made  to  harmonize  the 
eyes,  the  spectacles  ordered  should  suit  the  less  ametropic 
eye.  When  one  eye  is  E.  and  the  other  M.,  each  is  often 


PRESBYOPIA.  317 

used  for  seeing  at  different  distances,  and  both  remain 
perfect ;  but  if  one  be  As.  or  very  H.,  it  is  generally  de- 
fective from  want  of  use. 

PRESBYOPIA.    (Pr.) 

Presbyopia  (old  sight,  often  called  "long  sight")  is  the 
result  of  the  gradual  recession  of  p  which  takes  place  as 
life  advances,  and  which  causes  curtailment  of  the  range 
or  amplitude  of  A.  (p.  44).  From  the  age  of  ten  (or 
earlier)  onwards,  p  is  constantly  receding  from  the  eye. 
When  it  has  reached  9"  (22  cm.),  i.  e.,  when  clear  vision  is 
no  longer  possible  at  a  shorter  distance  than  22  cm.,  Pr. 
is  said  to  have  begun.  The  standard  is  arbitrary,  22  cm. 
having  been  fixed  by  general  agreement  as  the  point 
beyond  which  p  cannot  be  removed  without  some  incon- 
venience, the  point  where  age  begins  to  tell  on  the  practical 
efficiency  of  the  eyes  unless  glasses  are  worn.  In  the 
normal  eye  this  point  is  reached  soon  after  forty,  and  the 
rate  of  diminution  is  so  uniform  that  the  glasses  required 
to  bring  p  to  22  cm.  may  often,  if  necessary,  be  determined 
merely  from  the  patient's  age. 

But  as  allowance  has  to  be  made  for  any  error  of  refrac- 
tion (H.  or  M.),  and  as  there  are  exceptions  to  the  rule 
even  for  normal  eyes,  it  is  unsafe  in  practice  to  rely  on  age 
as  anything  more  than  a  general  guide. 

The  slow  failure  of  A.,  causing  Pr.,  depends  upon  senile 
changes  in  the  lens,  which  render  it  firmer  and  less  elastic, 
and  therefore  less  responsive  to  the  action  of  the  ciliary 
muscle.  There  can  be  little  doubt,  however,  that  failure 
of  the  ciliary  muscle  itself,  or  of  its  motor  nerves,  also 
forms  an  important  factor  in  some  cases,  particularly  when 
Pr.  comes  on  earlier  or  more  quickly  than  usual  (pp.  257 
and  264). 

As  Pr.  depends  on  a  natural  recession  of  the  near  point, 
27* 


318      KEFRACTION     AND     ACCOMMODATION. 

it  occurs  in  all  eyes  whether  their  refraction  be  E.,  M.,  or 
H.  In  M.,  however,  Pr.  sets  in  later  than  in  a  normal 
eye,  because  for  the  same  range  of  A.  the  region  is  always 
nearer  than  in  the  normal  eye.  In  H.,  on  the  contrary, 
Pr.  is  reached  sooner  than  is  normal,  because  for  the  same 
range  of  A.  the  region  is  always  further  than  in  the  normal 
eye.  Thus,  in  an  E.  eye  a  power  of  A.  =  4.5  D.  gives  a 
range  from  r  =  infinity  to  p  =  22  cm.  (the  focal  length  of 
4.5  D.,  see  p.  44),  i.  e.,  Pr.  is  just  about  to  begin.  In  a 
case  of  M.  2  D.  with  the  same  range,  the  region  of  A.  lies 
between  50  cm.  (the  r  for  this  eye)  and  15.5  cm.  (focal 
length  of  6.5  D.) ;  Pr.  has  not  yet  begun.  In  a  case  of  H. 
2  D.  with  the  same  range,  2  D.  of  A.  are  used  in  correct- 
ing the  H.,  i.  e.,  in  bringing  ?•  to  infinity,  and  only  2.5  D. 
of  A.  remains ;  p  is  therefore  at  40  cm.  (focal  length  of 
2.5  D.),  and  a  -f-  lens  of  2  D.  is  needed  to  bring  p  to  22 
cm. ;  there  is  Pr.  =  2  D.  The  only  cases  in  which  Pr. 
cannot  occur  are  in  M.  of  more  than  4.5  D.  If  M.  =  7  D., 
r  is  at  14  cm.,  and  though,  with  advancing  years,  p  will 
recede  to  14  cm.,  it  cannot  go  further,  and  the  patient 
therefore  never  becomes  presbyopic;  the  only  change  will 
be  the  loss  of  power  to  see  clearly  at  less  than  14  cm.  V. 
will  be  clear  at  14  cm.,  but  neither  nearer  nor  further. 

TREATMENT. — Convex  spectacles  are  found  by  the  aid 
of  the  Table  given  below,  with  which  the  patient  can  read 
at  22  cm. 

In  practice  it  is  always  proper  to  examine  for  H.  or  M., 
by  taking  the  distant  vision  and  trying  the  patient  for 
Hm.  (p.  304)  and  M.  (p.  296).  If  Hm.  be  found,  arm  the 
patient  with  the  glasses  which  neutralize  it  and  make  him 
E.,  and  then  add  to  them  the  glasses  that  should  by  the 
Table  be  required  to  bring  p  to  22  cm.  If  M.  be  found, 
subtract  the  amount  of  it  in  D.  from  the  convex  glass  that 
corresponds  to  his  age  in  the  Table. 

In  prescribing  for  Pr.  we  must  often  order  rather  less 


PRESBYOPIA. 


319 


than  the  full  correction.  For  instance,  if  A.  be  almost  en- 
tirely lost,  p  is  practically  removed  to  r,  and  the  glass 
which  will  bring  p  to  22  cm.  will  also  bring  r  to  the  same, 
or  nearly  the  same  point,  and  the  patient  will  be  able  to 
see  clearly  only  just  there.  Now  22  cm.  is  too  near  fbr 
sustained  vision,  and  such  patients  often  prefer  a  glass 
which  gives  them  a  near  point  of  from  30  to  40  cm.  (12" 
to  16"),  though  in  choosing  it  they  sacrifice  some  degree  of 
sharpness  of  sight.  The  difficulty  experienced  by  these 
patients  in  reading  with  glasses  which  give  p  =  22  cm.  de- 
pends on  the  unaccustomed  strain  which  is  thereby  thrown 
on  the  internal  recti ;  and  it  may  be  removed  or  lessened 
by  adding  to  the  convex  glasses  prisms  with  the  bases 
towards  the  nose  (Fig.  15);  or  by  putting  ordinary  convex 
spectacle  lenses  so  near  together  that  the  patient  looks 
through  the  outer  part  of  the  glass,  which  then  acts  as  a 
prism,  with  its  base  towards  the  nose  (Fig.  16). 

Presbyopia  Table  for  Emmetropic  Eyes. 


Distance  of 


Pr.  expressed  by  the  lens  necessary 
to  bring  f  to  22  cm.  or  9". 


Cm. 

Inches. 

Dioptres. 

Paris 
Inch  scale. 

40 

22 

9 

0. 

0 

45 

28 

11 

+  1. 

J-  ^g. 

50 

43 

17 

2. 

TV 

55 

67 

27 

3. 

TV 

60 

200 

72 

4. 

i 

65 

infi  nity. 

4.5                  i 

70 

acquired 

H.=l  D. 

5.5                 L 

75 

"   1.5  D. 

6.                   \ 

80 

"  2.5  D. 

7-                   i 

320      STRABISMUS    AND    OCULAR    PARALYSIS. 


CHAPTER    XXI. 

STRABISMUS    AND    OCULAR    PARALYSIS. 

STRABISMUS  exists  -whenever  the  two  eyes  are  not  (as 
they  ought  to  be)  directed  towards  the  same  object.  The 
eye  is  "directed  towards"  an  object  when  the  image  is 
formed  on  the  most  sensitive  part  of  the  retina  (the  yellow 
spot) ;  the  straight  line  joining  the  centre  of  this  image 
with  the  centre  of  the  object  is  the  "visual  axis"  (see  foot- 
note to  p.  33).  In  health  the  action  of  the  ocular  muscles 
is  such  as  to  keep  both  visual  lines  always  directed  to  the 
object  under  regard,  and  binocular  but  single  vision  is  the 
result.  Although  each  eye  receives  its  own  image,  only 
one  object  is  perceived  by  the  sensorium,  because  the  images 
are  formed  on  parts  of  the  retinse  which  "  correspond "  or 
are  "  identical "  in  function,  i.  e.,  which  are  so  placed  that 
they  always  receive  identical  and  simultaneous  stimuli. 

But  if,  owing  to  faulty  action  of  one  or  more  of  the 
muscles,  one  eye  deviate  and  the  visual  lines  cease  to  be 
directed  towards  the  same  object,  the  image  will  no  longer 
be  formed  on  the  yellow  spot  in  both  eyes.  In  one  of  them 
it  must  fall  on  some  other  and  non-identical  part  of  the 
retina,  and  the  result  is  that  two  images  of  the  same  object 
are  seen  (Diplopia,  p.  33).  In  Fig.  101  y  is  the  yellow- 
spot  in  each  eye,  and  the  visual  line  of  the  R.  eye  (the 
thick  dotted  line)  deviates  inwards;  hence  the  image  of 
the  object  (06.)  which  is  formed  at  y  in  the  L.  eye,  will  in 
the  R.  eye  fall  on  a  non-identical  part  to  the  inner  side  of 
y.  Ob.  will  be  seen  in  its  true  position  by  the  L.  eye.  To 
the  R.  eye,  however,  it  will  appear  to  be  at  F.  ob.,  because 


STKABISMTJS    AND    OCULAR     PARALYSIS.       321 

the  part  of  the  R.  retina  which  now  receives  the  image  of 
ob.  was  accustomed,  when  the  eye  was  normally  directed, 
to  receive  images  from  objects  in  the  position  of  F.  ob. ;  and 

FIG.  101. 


Shows  the  position  of  the  double  images  in  diplopia  from  convergent  or 
crossed  strabismus.  The  images  are  homonymous,  or  correspond  in  posi- 
tion to  the  eyes. 

in  consequence  of  this  early  habit  F.  ob.  is  the  position  to 
which  every  image  formed  on  this  part  of  the  retina  is 
referred. 

Hence  if  the  eye  deviate  towards  its  fellow  (convergent 
squint,  as  in  Fig.  101),  the  false  image  will  seem  to  the 
squinting  eye  to  be  in  the  opposite  direction ;  the  image 
belonging  to  the  R.  eye  being  referred  to  the  patient's  R., 
and  that  belonging  to  the  L.  eye  to  his  L. ;  in  convergent 


322       STHABISMUS    AND    OCULAR     PARALYSIS. 

or  crossed  strabismus,  the  double  images  correspond  in  po- 
sition to  the  eyes,  or  are  homonymous.  Similar  reasoning 
will  show  that  if  the  eye  deviate  from  its  fellow  (as  in 
Fig.  102,  divergent  squint),  the  position  of  the  double 

FIG.  102. 


Position  of  double  images  in  divergent  strabismus.   The  images  are  crossed 

images  must  he  reversed,  and  the  image  belonging  to  the 
R.  eye  appear  to  be  to  the  left  of  the  other;  hence  in  di- 
vergent squint  the  double  images  are  crossed. 

Since  the  image  of  ob.  in  the  squinting  eye  is  formed  on 
a  portion  of  the  retina,  more  or  less  distant  from  the  most 
perfect  part  (the  y.  $.),  it  will  not  appear  so  clear  or  so 
bright  as  the  image  formed  at  the  y.  s.  of  the  sound  (or 
"  working")  eye ;  it  is  called  the  "  false  "  image,  that  formed 
in  the  working  eye  being  the  "  true  "  one.  The  greater  the 


STRABISMUS    AND    OCULAR    PARALYSIS.      323 

deviation  of  the  visual  line  (i.  e.,  the  greater  the  squint)  the 
wider  apart  will  the  two  images  appear  and  the  less  dis- 
tinct will  the  "  false  "  image  be. 

[The  y.  s.  (?/)  of  the  R.  eye  will  receive  an  image  of 
some  different  object  lying  in  its  visual  line  (shown  by  the 
thick  dotted  line)  ;  this  image,  if  sufficiently  marked  to 
attract  attention,  will  be  seen,  and  will  appear  to  lie  upon 
the  image  of  ob.  seen  by  the  "working"  (L.)  eye;  two 
equally  clear  objects  will  be  seen  superimposed.  But,  as  a 
rule,  only  one  of  these  images  is  attended  to,  the  perception 
of  the  other  being  habitually  suppressed,  even  sooner  than 
that  of  the  "false  image"  (p.  238);  the  suppressed  image 
always  belongs  to  the  squinting  eye.] 

Squinting  is  not  always  accompanied  by  double  vision 
because  :  (1)  if  the  deviation  be  extreme,  the  false  image 
is  formed  on  a  very  peripheral  part  of  the  retina,  and  is  so 
dim  as  not  to  be  noticed ;  conversely,  the  less  the  squint 
the  more  troublesome  is  the  diplopia,  when  present  (p.  33) ; 
(2)  as  already  mentioned,  after  a  time  the  "false  image" 
is  suppressed  (p.  238). 

For  the  method  of  examining  for  strabismus  and  di- 
plopia, see  pp.  32  and  33. 

Strabismus  may  arise  from  any  one  of  the  following  mus- 
cular conditions:  (1)  over-action;  (2)  weakness  following 
over-use ;  (3)  disuse  of  an  eye  whose  sight  is  defective  ;  (4) 
stretching  and  weakening  of  the  tendon  after  tenotomy; 
(5)  from  paralysis  of  one  or  more  muscles. 

(1)  Over-action  of  the  internal  recti  gives  rise  to   the 
convergent  squint  of  hypermetropia  (p.  302).    Occasionally 
convergent  squint  occurs  in  myopia.     Both  forms  are  con- 
comitant (p.  33),  but  in  cases  of  old  standing  the  range  of 
movement  of  the  squinting  eye  is  often  deficient. 

(2)  Strabismus    from    weakness    (muscular   asthenopia, 
pp.  244  and  290)  always  depends  on  weakening  of  the  in- 
ternal rectus,  and  is  consequently  divergent.     It  is  com- 


324      STRABISMUS    AND    OCULAR    PARALYSIS. 

monest  in  M.,  but  is  not  infrequent  iu  H.,  and  even  in  Em. 
The  eye  can  usually  be  moved  into  the  inner  canthus,  even 
in  extreme  cases,  by  making  the  patient  look  sideways, 
though  not  by  efforts  at  convergence,  and  it  is  thus  but 
rarely  that  these  cases  simulate  paralysis.  Tenotomy  of 
the  external  rectus  and  "advancement"  of  the  weakened 
muscle  are  often  needed. 

(3)  Strabismus  from  disuse  is  also  nearly  always  diver- 
gent, depending,  as  it  does,  on  relaxation  of  the  internal 
rectus.     It  occurs  in  cases  where  convergence  is  no  longer 
of  service,  as  when  one  eye  is  blind  from  opacity  of  the 
cornea  or  other  cause,  or  where  the  refraction  of  the  two 
eyes  is  very  different  (p.  316).     Treatment  is  seldom  use- 
ful, but  tenotomy  of  the  external  rectus  may  be  called  for. 

(4)  Stretching  and  weakening  of  the  internal   rectus 
after  division  of  its  tendon  for  convergent  squint  may  give 
rise  to  divergence  simulating  that  caused  by  paralysis  of 
the  internal  rectus.     The  caruncle  in  these  cases,  however, 
is  generally  much  retracted,  and  this,  together  with  the 
history  of  a  former  operation,  will  prevent  any  mistake  in 
diagnosis.     The  squint  can  always  be  lessened,  and  often 
quite  removed,  by  an   operation  for  "readjustment"  or 
"  advancement "  of  the  defective  muscle. 

(5)  Paralytic  squint. — The  deviation  is  caused  by  the 
unopposed  action  of  the  sound  muscles.     When  the  palsied 
muscle  tries  to  act,  the  eye  fails,  in  proportion  to  the  weak- 
ness, to  move  in  the  required  direction.     In  many  cases 
there  is  only  slight  paresis,  and  the  resulting  deviation  is 
too  little  to  be  objectively  noticeable ;  but  in  such  cases 
the  diplopia,  as  mentioned  already,  is  very  troublesome, 
and  it  is  for  this  symptom  that  the  patient  comes  under 
care.     Further,  in  these  slight  cases  the  symptoms  often 
vary  with  variations  in  the  effort  made  by  the  patient.     In 
paralysis  of  the  third  nerve  the  several  branches  are  often 
affected  in  different  degrees,  and  the  resulting  strabismus 


STRABISMUS    AND    OCULAR    PARALYSIS.       325 

and  diplopia  are  then  complex.  When  paralysis  is  of  long 
standing  secondary  contraction  of  the  opponent  seems  some- 
times to  occur,  still  further  complicating  the  symptoms. 
Lastly,  the  sound  yoke-fellow1  of  the  paralyzed  muscle 
sometimes  acts  too  much  in  obedience  to  efforts  made  by 
the  latter,  and  in  this  way  the  squint  may  occasionally, 
even  when  both  eyes  are  uncovered,  affect  the  sound  instead 
of  the  paralyzed  eye,  i.  e.,  the  squint  may  be  alternating. 
(Compare  Secondary  Squint,  p.  32.) 

The  commonest  forms  of  paralytic  squint  are  due  to 
affection,  separately,  of  the  external  rectus  (sixth  nerve), 
superior  oblique  (fourth  nerve),  or  of  one  or  all  of  the 
muscles  supplied  by  the  third  nerve  (internal,  superior  and 
inferior  recti,  inferior  oblique,  levator  palpebrse). 

Paralysis  of  the  external  rectus  (sixth  nerve)  causes  a 
convergent  squint  from  preponderance  of  the  internal 
rectus;  and  this,  except  in  the  slightest  cases,  is  very 
noticeable.  Movement  straight  outwards  is  impaired,  and 
if  the  paralysis  be  complete  the  eye  cannot  be  moved 
outwards  beyond  the  middle  line  of  the  palpebral  fissure. 
There  is  homonymous  diplopia;  the  two  images,  when  in 
the  horizontal  plane,  are  upright  and  on  the  same  level; 
the  distance  between  them  increases  as  the  object  is  moved 
towards  the  paralyzed  side,  but  it  diminishes,  or  the  images 
even  coalesce,  in  the  opposite  direction.  Thus,  in  paralysis 
of  the  left  external  rectus  (Fig.  102,  uppermost  figure),  the 
images  separate  more  as  the  object  is  moved  to  the  patient's 
left,  but  approach  one  another,  and  finally  coalesce  as  it  is 
moved  over  to  his  right.  In  slight  cases  the  diplopia  ceases 
during  convergence  for  a  near  object,  but  reappears  when 
gazing  straight  forwards  at  a  distant  object.  In  the  upper 

1  Yoked  or  conjugate  muscles  are  the  muscles  of  opposite  eyes 
which  act  together  in  producing  lateral  and  vertical  movements  ; 
e.  g.,  the  internal  rectus  of  one  eye  acts  with  the  external  rectus 
of  the  other  in  movement  of  the  eyes  to  the  K.  or  L. 

28 


326      STRABISMUS    AND    OCULAR    PARALYSIS. 

part  of  the  field  the  false  image  is  sometimes  lower  than 
the  true  one,  and  in  the  lower  part  of  the  field  it  is  higher. 

In  paralysis  of  the  superior  oblique  (fourth  nerve)  there  is 
either  no  visible  squint,  or  only  a  slight  deviation  upwards 
and  inwards.  But  when  the  eyes  are  directed  below  the 
horizontal  very  troublesome  diplopia  arises  from  the  defec- 
tive downward  and  outward  movement,  and  loss  of  rotation 
of  the  vertical  meridian  inwards,  to  which  the  lesion  gives 
rise.  In  downward  movements,  especially  downwards  and 
towards  the  paralyzed  side,  the  eye  remains  a  little  higher 
than  its  fellow ;  in  trying  to  look  straight  down  (inferior 
rectus  and  superior  oblique)  the  unopposed  action  of  the 
inferior  rectus  carries  the  cornea  somewhat  inwards  (con- 
vergent squint),  and  at  the  same  time  rotates  the  vertical 
axis  outwards,  whilst  the  cornea  remains  on  a  rather 
higher  level  than  its  fellow ;  in  following  an  object  from 
the  horizontal  middle  line  down  outwards  it  will  be  seen 
the  vertical  meridian  of  the  cornea  does  not,  as  it  should, 
become  inclined  inwards. 

In  many  cases,  however,  the  slight  defects  of  movement 
caused  by  paralysis  of  the  superior  oblique  are  not  clearly 
marked,  and  the  diagnosis  has  to  be  based  on  the  charac- 
ters of  the  diplopia  (compare  p.  33).  In  all  positions 
below  the  horizontal  line  the  false  image  will  be  below 
the  true  one,  and  displaced  towards  the  paralyzed  side 
(homonymous) ;  thus,  if  the  R.  muscle  be  at  fault  the  false 
image  will  be  below  and  to  the  patient's  R.  (Fig.  103, 
arrow-headed  figure) ;  further,  it  will  not  be  upright,  but 
will  lean  towards  the  true  image.  The  difference  in 
height  between  the  images  is  greatest  in  movements  to- 
wards the  sound  side ;  the  lateral  separation  is  greater 
the  further  the  object  is  moved  downwards ;  the  leaning 
of  the  false  image  is  greatest  in  movements  towards  the 
paralyzed  side.  When  the  patient  looks  on  the  floor,  i.  e., 
projects  the  images  on  to  a  horizontal  surface,  the  false 


STRABISMUS    AND     OCULAR    PARALYSIS.       327 

image  seems  nearer  to  him  than  the  true  one.  The  images 
are  always  near  enough  together  to  cause  inconvenience, 
and  as  the  diplopia  is  confined  to,  or  is  worst  in,  the  lower 
half  of  the  field,  the  half  most  used  in  daily  life,  paralysis 
of  the  superior  oblique  is  very  annoying,  especially  in  going 

FIG.  103. 


Chart  showing  position  of  double  images  as  seen  by  the  patient  in 
paralysis  of  L.  external  rectus  and  R.  superior  oblique. 

up  or  down  stairs,  in  looking  at  the  floor,  counting  money, 
and  similar  acts. 

Paralysis  of  the  third  nerve,  when  complete,  causes 
ptosis,  loss  of  inward,  upward,  and  downward  movements, 
loss  of  accommodation,  and  partial  mydriasis.  There  is 
well-marked  divergent  strabismus  from  unopposed  action 
of  the  external  rectus.  The  slight  downward  and  outward 
movement,  with  rotation  of  the  vertical  meridian  inwards, 
effected  by  the  superior  oblique  remains.  The  diplopia  is 
crossed.  The  mydriasis  is  much  less  than  that  produced 
by  atropine.  In  the  majority  of  cases,  paralysis  of  the 
third  is  incomplete,  affecting  some  branches  (and  muscles) 
more  than  others,  and  the  result  is  a  less  typical  condition 
than  the  above.  Complete  isolated  paralysis  of  a  single 
third  nerve  muscle  is  very  rare. 


328      STRABISMUS    AND    OCULAR    PARALYSIS. 

Peculiarities  of  paralytic  strabismus. — (1)  If  a  patient 
suffering,  e.  g.,  from  paresis  of  one  external  rectus,  look  at- 
tentively at  an  object  held  at  a  distance  of  about  two  feet, 
and  the  sound  eye  be  then  covered  by  holding  a  card  (or 
better,  a  piece  of  ground  glass)  before  it,  the  paralyzed  eye 
will  make  an  attempt  (more  or  less  successful  according  to 
the  degree  of  the  palsy)  to  look  at  the  object.  The  move- 
ment effected  will  call  for  a  greater  effort  than  if  the  sixth 
nerve  were  healthy,  and  as  the  eye  muscles  always  work  in 
pairs,  the  same  effort  will  be  transmitted  to  the  internal 
rectus  of  t'.ie  healthy  eye.  The  latter  will,  in  consequence, 
describe  a  larger  movement  than  the  paralyzed  eye,  i.  e.,  the 
secondary  squint  will  be  greater  than  the  primary  (p.  33). 
This  test  is  sometimes  of  use  in  distinguishing  which  is  the 
faulty  eye,  in  cases  where  the  squint  is  slight  and  the 
patient  unable  to  distinguish  between  the  false  and  true 
images  (p.  34).  (2)  Giddiness  is  often  present  when  the 
patient  walks  with  the  sound  eye  closed.  This  symptom 
depends  on  an  erroneous  judgment  of  the  position  of  sur- 
rounding objects,  which  is  caused  by  the  weakened  muscle 
not  being  able  to  achieve  a  movement  of  the  eye,  corre- 
sponding in  magnitude  to  the  effort  which  it  makes.  This 
symptom  is  absent  when  both  eyes  are  open,  and  when  the 
paralyzed  eye  is  covered.  It  often  gives  us  more  aid  than 
the  former  symptom  in  determining  which  is  the  faulty 
eye;  it  varies  much  in  severity  in  different  cases,  and  may 
be  quite  absent. 

Paralysis  of  the  ocular  muscles  is  seldom  symmetrical ; 
in  the  rare  cases  where  it  is  so,  the  disease  is  usually  in- 
tracranial,  and  probably  in  most  cases  nuclear,  though 
symmetrical  disease  of  nerve  trunks  has  been  found  in  some 
cases.  In  certain  rare  cases  of  symmetrical  paralysis  of 
all  the  ocular  muscles  (" ophthalmoplegia  externa"),  which 
depend  on  nuclear  disease,  other  cranial  nerves  (especially 


STRABISMUS    AND    OCULAR    PARALYSIS.      329 

the  optic  and  fifth)  are  often  involved,  and  symptoms  of 
spinal  or  bulbar  disease  often  present. 

PARALYSIS  OF  THE  INTERNAL  MUSCLES  OF  THE  EYEBALL. 

The  three  internal  muscles  are  supplied  by  two  nerves ; 
the  ciliary  muscle  and  sphincter  of  the  pupil  by  the  third 
nerve  (short  root  of  lenticular  ganglion),  the  dilator  of  the 
pupil  by  the  sympathetic,  but  whether  from  the  lenticular 
ganglion  or  by  branches  independent  of  that  structure  is 
uncertain.  The  following  paralytic  states  of  these  three 
muscles  are  to  be  distinguished. 

A.  Iris   affected    alone. — (1)  Paralysis  of  the  dilator. 
The  pupil  in  moderate  light  is  equal  to  or  rather  smaller 
than  the  other;  in  a  bright  light  it  contracts  a  little,  but 
when  shaded  does  not  dilate,  and  hence,  if  the  eyes  be  ex- 
amined in  a  dull  light,  the  paralyzed  pupil  will  be  much 
smaller  than  its  fellow  (paralytic  myosis^);  accommodation 
is  not  affected.     This  state  of  the  pupil  occurs  in  paralysis 
of  the  cervical  sympathetic,  and  perhaps  under  other  con- 
ditions; in  a  certain  degree  it  is  common,  perhaps  natural, 
to  old  age.     (2)  Paralysis  of  the  sphincter  alone  (paralytic 
mydriasis)  causes  moderate  dilatation;  the  pupil  remains 
of  the  same  size  m  the  brightest  light,  and  accommodation 
is  unaffected.     It  is  very  rare.     (3)  Paralysis  of  both  iridal 
muscles  without  affection  of  accommodation  (iridoplegia). 
The  pupil  is  of  medium  size  and  uninfluenced  by  varia- 
tions of  light ;  but  its  associated  action  (p.  39)  is  usually 
retained,  except  in  very  advanced  cases. 

B.  Ciliary  muscle  paralyzed  alone  (Cycloplegia). — Ac- 
commodation is  lost  without  any  change  in  the  activity  of 
the  pupil.     The  term  is  applied  only  to  cases  of  nervous 
origin,  not  to  presbyopia.     The  condition  is  very  rare  ex- 
cept after  diphtheria,  when  paralysis  (often  only  paresis) 
of  accommodation,  with  little  or  no  affection  of  iris,  is 
common. 

28* 


330      STRABISMUS    AND    OCULAR    PARALYSIS. 

c.  Ciliary  muscle  and  iris  both  affected. — (1)  Mydriasis 
with  cycloplegia;  partial  dilatation  of  the  pupil  (to  about 
4  or  5  mm.),  with  loss  of  accommodation.  This  is  the 
common  condition  in  complete  paralysis  of  the  third  nerve, 
and  in  rare  cases  it  is  seen  without  failure  of  any  other 
part  of  the  nerve.  (2)  Paralysis  of  all  the  three  internal 
muscles  ("  ophthalmoplegia,  interna"  Hutchinson) ;  loss  of 
accommodation  with  immobility,  both  "associated,"  and 
"  reflex,"  of  the  iris,  the  pupil  being  of  about  medium  size. 

CAUSES  OF  OCULAR  PARALYSIS. 

It  is  convenient  to  separate  the  external  and  mixed 
forms  from  those  in  which  only  the  internal  muscles  are 
involved,  since  the  local  causes  are,  as  a  rule,  different  in 
the  two  groups. 

Paralysis  of  the  third,  fourth,  or  sixth  nerve  may  be  the 
result  of  tumors  or  other  growths  in  the  orbit,  but  in  such 
cases,  as  a  rule,  the  paralysis  forms  only  one  amongst  other 
well-marked  local  symptoms.  In  the  vast  majority  of 
uncomplicated  ocular  palsies  there  is  nothing  in  the  state 
of  the  eye  or  the  orbital  parts  to  guide  us  in  determining 
whether  the  disease  is  seated  in  the  orbit  or  within  the 
cranium.  Meningitis,  morbid  growths,  and  syphilitic  peri- 
ostitis at  the  base  of  the  skull  or  involving  the  sphenoidal 
fissure  often  cause  ocular  palsy,  seldom  confined  to  one 
nerve,  and  aneurism  of  the  internal  carotid  in  the  cavern- 
ous sinus  occasionally  does  so.  Syphilitic  gumma  of  the 
nerve-trunk  is  probably  the  commonest  cause  of  single 
paralysis;  the  intracranial  portion  of  the  nerve  is  known 
to  be  often  the  seat  of  such  growths,  but  neural  gummata 
probably  occur  also  on  the  orbital  part  of  the  nerves  where 
they  are  too  small  to  cause  protopsis  or  signs  of  inflamma- 
tion. Fractures  of  the  skull  often  lead  to  ocular  paralysis 
by  compression  of  a  nerve,  either  by  displacement  of  bone 


STRABISMUS    AND    OCULAR    PARALYSIS.      331 

or  by  inflammatory  exudation  afterwards  thrown  out. 
Paralysis  of  the  third  nerve,  coming  on  simultaneously 
with  hemiplegia  of  the  opposite  side,  may  indicate  a  lesion 
in  the  crus  cerebri  on  the  side  of  the  paralyzed  third.  In 
certain  cases  there  are  neither  symptoms  nor  facts  enabling 
us  to  locate  the  seat,  or  prove  the  cause,  of  the  paralysis. 
The  term  "  rheumatic  "  is  often  applied  to  such  cases  on 
the  assumption  that  the  palsy  is  peripheral  and  caused  by 
cold,  that  it  is,  in  fact,  to  be  compared  to  peripheral  pa- 
ralysis of  the  facial  nerve ;  no  doubt  some  of  them  are  in 
reality  syphilitic  cases.  Paralysis,  usually  of  short  dura- 
tion and  affecting  only  one  nerve,  is  not  uncommon  at  an 
early  stage  of  locomotor  ataxy.  Ophthalmoplegia  externa 
generally  sets  in  slowly,  is  permanent,  and  indicates  disease 
of  the  nerve  centres  ;  it  is  usually  caused  by  syphilis,  but 
occasionally  it  is  "  functional "  and  passes  off. 

In  respect  to  the  causation  of  the  internal  paralyses  we 
have  but  little  positive  knowledge.  Mydriasis,  with  cyclo- 
plegia  and  no  other  paralysis,  could  be  best  accounted  for 
by  the  supposition  of  disease  of  the  short  (third  nerve)  root 
of  the  lenticular  ganglion.  Iridoplegia  and  ophthalmo- 
plegia  interna  are  probably  the  result  of  chronic,  very 
strictly  localized,  disease  of  the  centres  for  the  pupil  and 
accommodation  (Gowers),  which  have  been  shown  to  form 
separate  parts  of  the  nucleus  of  the  third  nerve.  Complete 
ophthalmoplegia  interna  would  also  occur  if  the  lenticular 
ganglion  (Hutchinson)  or  the  intraocular  ganglionic  cells 
of  the  choroid  (Hulke)  were  disorganized  ;  but  such  changes 
have  not  yet  been  proved  post-mortem. 

TREATMENT  OP  OCULAR  PARALYSES.  —  In  estimating 
the  results  of  treatment  it  is  well  to  remember  that  some 
cases  recover  spontaneously,  that  in  many  the  defect  is  a 
paresis  rather  than  paralysis,  and  that  in  the  latter  cases 
the  symptoms  often  vary  in  severity  from  day  to  day,  or 
even  whilst  under  observation  at  a  single  visit,  according 


332      STRABISMUS    AND    OCULAR    PARALYSIS. 

to  the  attention  and  effort  given  by  the  patient.  The  ques- 
tions of  syphilis  and  of  injury  to  the  head  are  always  to  be 
carefully  inquired  into,  especially  when  only  one  nerve  is 
paralyzed.  When  several  nerves  are  involved,  tumor, 
aneurism,  or  syphilis  (either  gummatous  inflammation  at 
the  base,  or  sclerotic  nuclear  disease)  are  to  be  suspected ; 
in  the  nuclear  cases  there  is  usually  bilateral  symmetry. 
Iodide  of  potassium  and  mercury  are  the  only  internal 
remedies  likely  to  be  beneficial,  and  unless  syphilis  be  quite 
out  of  the  question  they  should  have  a  full  trial ;  many 
cases  recover  quickly  under  moderate  doses  of  iodide. 
Faradization  of  the  paralyzed  muscles  is  sometimes  used. 

Nystagmus  (involuntary  oscillating  movement  of  the 
eyes)  is  generally  associated  with  serious  defect  of  sight 
dating  from  very  early  life,  such  as  opacity  of  the  cornea 
after  ophthalmia  neouatorum,  congenital  cataract,  choroido- 
retinitis,  or  disease  of  the  optic  nerve.  It  is,  however,  also 
seen  in  cases  of  infantile  amblyopia  without  apparent  cause, 
and  constantly  in  albinoes.  Nystagmus  is  often  developed 
during  adult  life,  in  coal-miners,  and  is  probably  caused 
either  by  the  insufficiency  of  light  furnished  by  the  safety 
lamps  or  by  the  necessity  which  the  miner  is  under  of  con- 
stantly looking  in  an  unnatural  direction,  upwards  or  side- 
ways for  example.  It  is  often  present  only  when  the  collier 
takes  up  his  mining  posture.  Nystagmus  also  forms  a 
symptom  in  some  cases  of  disseminated  sclerosis. 

In  most  cases  both  eyes  are  affected,  but  unilateral  nys- 
tagmus may  occur  when  only  one  eye  is  defective.  The 
movements  in  nystagmus  vary  much  in  rapidity,  amplitude 
and  direction  in  different  cases,  and  even  in  the  same  case 
at  different  times ;  they  are  generally  worse  when  the  patient 
is  frightened  or  nervous,  and  often  there  is  a  particular  po- 
sition of  the  eyes  in  which  the  movement  is  least.  In  many 
cases  the  nystagmus  becomes  much  less  marked  as  life  ad- 
vances. Treatment  is  useless. 


OPERATIONS.  333 


CHAPTER    XXII. 

OPERATIONS. 

A.  OPERATIONS  ON  THE  EYELIDS. 

1.  Epilation    in    ophthalmia    tarsi. — Position:    patient 
seated;  surgeon  standing  behind.     The  forceps  to  be  broad- 
ended,  Avith  smooth  or  very  finely  roughened  blades  which 
meet  accurately  in    their   whole  -width.     Stretch   the   lid 
tightly  by  a  finger  placed  over  each  end.     Pull  out  the 
lashes  at  first  quickly  in  bundles,  and  finish  by  carefully 
picking,  out  the  separate  ones  that  are  left. 

2.  Eversion  of  upper  lid. — Position  as  for  1,  or  the  sur- 
geon may  stand  in  front.     The  patient  looks  down,  a  probe 
is  laid  along  the  lid  above  the  upper  edge  of  the  "car- 
tilage," the  lashes  or  the  edge  of  the  lid  are  then  seized  by 
a  finger  and  thumb  of  the  other  hand,  and  turned  up  over 
the  probe,  which  is  simultaneously  pushed  down.     After  a 
little  practice  the  probe  can  be  dispensed  with,  and  the  lid 
everted  by  the  forefinger  and  thumb  of  one  hand  alone,  one 
serving  to  fix  and  depress  the  lid,  the  other  to  turn  it  up- 
wards. 

3.  Removal  of  Meibomian  cyst. — Position  as  for  1.     In- 
struments: a  small  scalpel  or  Beer's  knife  (Fig.  135),  and 

FIG.  104. 


Meibomian  scoop. 

a  curette,  or  small  scoop  (Figs.  104,  and  131).     (1)  Evert 
the  lid;  (2)  make  a  free  crucial  incision  into  the  tumor 


334 


OPERATIONS. 


from  the  conjunct! val  surface;  (3)  remove  the  growth 
either  by  squeezing  the  lid  between  finger  and  thumb-nail, 
or  by  means  of  the  scoop.  The  cavity  fills  with  blood,  and 
may  thus  for  a  few  days  be  larger  than  before.  These 
tumors  have  no  distinct  cyst-wall. 

4.  Inspection  of  cornea  in    purulent  ophthalmia,  etc. 
Position  :  if  the  patient  be  a  baby  or  child,  the  back  of  its 

FIG.  105. 


FIG.  10f». 


Desmarres'  lid  elevator. 

head  is  to  be  held  between  the  surgeon's  knees,  its  body 
and  legs  being  on  the  nurse's  lap;  if  r.n  adult,  the  same  as 
for  1.  If  the  lids  cannot  be  easily 
separated  by  a  finger  of  each  hand 
enough  to  allow  a  view  of  the 
cornea,  retractors  should  be  used 
(a  convenient  pattern  is  shown  in 
Fig.  105),  by  which  one  or  both 
lids  can  be  raised  and  held  away 
from  the  globe.  If  this  instru- 
ment be  gently  used,  we  avoid 
all  risk  of  causing  perforation  of 
the  cornea  should  a  deep  ulcer 
be  present,  an  accident  which 
may  happen  in  cases  attended  by 
much  swelling  or  spasm  of  the 
lids  if  the  fingers  are  used. 

5.  Entropion. — Spasmodic  entropion  of  the  lower  lid,  with 
relaxed  skin,  in  old  people.  Position  as  for  1.  Instru- 
ments: T  forceps  (Fig.  106),  scissors  (Fig.  116),  toothed 
forceps.  (1)  With  the  T  forceps  pinch  up  a  fold  of  skin 


Entropion  forceps. 


EYJ3LIDS    AND    CONJUNCTIVA.  335 

as  close  as  possible  to  the  edge  of  the  lid  and  of  width 
proportionate  to  the  degree  of  inversion,  and  cut  it  off 
close  to  the  forceps ;  (2)  Avith  the  toothed  forceps  pinch  up 
the  orbicularis  muscle  now  exposed,  and  cut  out  a  small 
piece.  Sutures  need  not  be  used. 

6.  Organic  entropion  and  trichiasis. — When  the  whole 
row  of  lashes  is  turned  inwards,  and  the  inner  surface  of 
the  lid  much  shortened  by  scarring,  the  radical  extirpation 
of  all  the  lashes  is  the  quickest  and  most  certain  means  of 

FIG.  107. 


Snellen's  lid  clamp  (for  the  R.  upper  lid). 

giving  permanent  relief,  but  it  leaves  an  unsightly  bald- 
ness and  exposes  the  cornea  to  unnatural  risk  from  dust, 
etc.  Position:  recumbent;  the  surgeon  stands  behind  the 
patient.  Anaesthesia  seldom  necessary.  Instruments:  a 
horn  or  bone  lid-spatula,  or  a  lid  clamp  (Fig.  107),  a  small 
scalpel  or  Beer's  knife,  and  forceps.  Make  an  incision 
from  end  to  end  (beginning  just  outside  the  punctum)  be- 
tween the  hair-follicles  and  Meibomian  ducts,  as  if  about 
to  split  the  lid  into  two  layers.  Then  make  a  second  inci- 
sion through  the  skin  and  tissues,  about  one-twelfth  of  an 
inch  beyond  the  border  of  the  lid  in  a  plane  at  right 


336  OPERATIONS. 

angles  to  the  first.  The  strip  of  skin  and  tissues  included 
between  these  two  cuts  will  now  be  almost  free,  except  at 
its  ends,  which  are  to  be  united  by  a  cross-cut,  and  the 
strip  dissected  off;  it  should  include  the  hair-follicles  in 
their  whole  depth.  Examine  the  white  edge  of  the  carti- 
lage, now  exposed,  for  any  hair-follicles  accidentally  left 
behind ;  they  will  appear  as  black  dots,  which  are  to  be 
carefully  removed,  lest  they  should  produce  fresh  hairs. 

In  the  same,  or  slighter  cases,  the  inversion  of  the  border 
of  the  lid  may  be  much  lessened  by  complete  division  of 
the  "  cartilage  "  from  the  conjunctival  surface  along  a  line 
parallel  with  and  3  mm.  from  the  free  border  (Burow's 
operation)  (Fig.  109,  Bu).  The  wound  gapes  and  the 
inverted  border  of  the  lid  falls  forward  and  is  kept  in  its 
natural  place  by  the  cornea.  The  only  instruments  needed 
are  a  scalpel  and  scissors.  Position  as  for  1,  or  recumbent. 
The  lid  is  kept  well  everted  whilst  the  incision  is  being 
made.  A  puncture  is  made  with  the  knife  parallel  to  the 
edge  of  the  lid,  close  to  the  inner  or  outer  end,  one  blade 
of  the  scissors  passed  in  and  made  to  run  along  the  outer 
surface  of  the  "  cartilage  "  between  it  and  the  orbicularis 
muscle,  and  then  the  "  cartilage  "  divided  by  closing  the 
blades  parallel  to  the  border.  The  wound  should  be  at 
right  angles  to  the  surface.  A  bluish  line  should  be  seen 
through  the  skin  on  replacing  the  lid.  This  operation  gives 
complete  relief  for  the  time,  but  may  need  repetition  in  a 
few  months. 

Various  operations  are  performed  for  transplantation  of 
the  displaced  lashes  forwards  and  upwards,  so  as  to  restore 
their  natural  direction.  Arlt's  operation. — The  free  border 
of  the  lid  is  split  from  end  to  end  (leaving  the  punctum), 
as  for  extirpation  of  the  lashes,  but  much  more  deeply 
(Fig.  108,  a).  A  second  incision  (6),  extending  beyond 
the  ends  of  the  first,  is  now  made  through  the  skin  par- 
allel to,  and  about  two  lines  from,  the  border  of  the  lid, 


EYELIDS    AND     CONJUNCTIVA.  337 

and  down  to,  but  not  through,  the  "cartilage;"  thirdly,  a 
curved  incision  (c)  is  made,  joining  b  at  each  end  and  in- 
cluding, therefore,  a  semilunar  flap  of  skin,  of  greater  or 
less  width  according  to  the  effect  desired.  This  flap  is  now 

FIG.  108. 


Aril's  operation  for  trichiasis.     (After  Schweigger.) 

dissected  off  without  injury  to  the  orbicularis,  and  the  edges 
of  the  wound  are  brought  together  with  sutures.  The  an- 
terior layer  of  the  lid  border,  which  contains  the  lashes,  is 
thus  tilted  forwards  and  drawn  upwards. 

If  more  effect  be  wanted,  a  wedge-shaped  strip  of  the 
tarsal  cartilage  may  be  removed  parallel  with,  and  about 
a  line  from,  the  border  of  the  upper  lid,  by  cutting  through^ 
or  separating,  the  fibres  of  the  orbicularis  after  the  skin, 
flap  has  been  removed.  The  groove  thus  made  allows  of 
more  complete  eversion  of  the  border  (Soelberg  Wells' 
combination  of  Arlt's  and  Streatfield's  operations). 

A  third  operation  (Streatfield's)  consists  in  the  simple 
removal  of  a  wedge-shaped  strip  of  the  "  cartilage  "  (with 
its  superjacent  skin  and  muscle),  from  the  whole  length  of 
the  lid,  at  a  distance  of  a  line  or  two  from  its  border 
(b,  Fig.  108).  No  sutures  are  used. 

29 


338 


OPERATIONS. 


FIG.  109. 


Snellen  operates  as  follows:  The  incision  (6,  Fig.  108) 
is  carried  down  to  the  tarsus,  the  muscle  and  skin  separated 
and  pushed  upwards,  and  a  wedge, 
shown  by  the  groove  in  Fig.  109, 
cut  from  the  exposed  tarsus,  as  in 
Streatfield's  operation.  The  border 
of  the  lid  is  now  everted  and  kept 
in  its  new  position  by  passing  two 
or  three  threads  as  shown  in  Figs. 
109  and  110,  and  tying  them  over 
beads.  The  skin  wound  need  not 
be  sutured. 

All  these  operations  (except  1) 
are  apt  to  need  repetition  sooner  or 
later. 

7.  Ectropion.  —  Ectropion  from 
thickening  of  the  conjunctiva,  aided 
by  relaxation  of  the  tissues  of  the 
lower  lid,  as  seen  chiefly  in  old  peo- 
ple, is  best  treated  by  the  removal 
of  a  V-shaped  piece  of  the  whole 
thickness  of  the  lid,  the  edges  being  brought  together  with 
one  or  two  harelip  pins.  Another  plan  is  to  excise  a  hori- 
zontal fold  of  the  palpebral  conjunctiva  corresponding  to 
the  most  everted  part ;  the  contraction  of  the  scar  draws 
the  margin  of  the  lid  into  place.  In  a  third  procedure  the 
everted  mucous  membrane  is  drawn  back  into  the  sulcus 
between  lid  and  globe  by  a  thick  suture  entered  at  two 
points  J  inch  apart,  passed  deeply,  brought  out  on  the 
cheek,  and  tied  over  a  bit  of  India-rubber  tube ;  this  thread 
is  not  to  be  left  in  more  than  three  days. 

For  ectropion  from  cicatricial  changes  in  the  skin  some 
kind  of  plastic  operation  is  generally  necessary.  It  is 
generally  advantageous  at  the  same  time  to  unite  the  eye- 
lids temporarily  by  paring  the  narrowest  possible  strip 


Diagrammatic  section 
of  upper  lid,  showing 
Snellen'a  operation;  and 
line  of  section  in  Burow's 
operation  (Bu).  (Altered 
from  Wecker.) 


EYELIDS    AND     CONJUNCTIVA. 


339 


from  the  border  of  each  lid  within  the  line  of  the  lashes, 
and  passing  a  few  very  fine  sutures.  The  lids  are  to  be 
separated  a  few  weeks  later.  The  operation  for  the  cure 
of  the  ectropion  will  naturally  vary  with  the  seat,  extent, 
and  cause  of  the  deformity,  but  we  may  conveniently  dis- 
tinguish three  varieties  of  organic  ectropion,  according  as 
the  condition  has  followed :  (1)  a  wound  of  the  eyelid  with 
faulty  union ;  (2)  a  deeply  adherent  scar  from  abscess,  dis- 
ease of  bone,  or  deep  ulceration  of  the  lid  ;  or  (3)  extensive 
scarring  of  the  face  from  burns,  lupus,  etc.  When  the 

FIG.  110. 


Snellen's  operation  for  trichiasis.     (After  \Vecker.)    s.  Edge  of 
retracted  skin  and  muscle. 

cause  is  quite  localized  and  there  is  not  much  loss  of  tissue 
(groups  1  and  2)  the  scar  may  be  included  in  a  Y-shaped 
incision,  the  flap  separated  and  pushed  up  till  the  lid  is  in 
position,  and  the  lower  part  of  the  wound  then  brought 
together  by  a  pin  or  sutures,  so  that  what  was  a  V  now  be- 
comes a  Y,  the  edges  of  the  flap  being  attached  by  sutures 
to  the  limbs  of  the  Y-  As  the  lid  has  generally  become  too 
long,  from  the  prolonged  eversion,  it  is  often  best,  at  the 
same  time,  to  shorten  it  by  removing  a  small  triangular 
piece  of  the  lid  at  the  outer  canthus  and  stitching  the 
edges  of  the  gap  together.  When  the  position  of  the 
deformity  prevents  the  above  operation  it  is  necessary  to 
introduce  new  skin  into  the  gap  made  by  dissecting  out  the 


340  OPERATIONS. 

cicatricial  tissue  and  replacing  the  everted  lid.  The  ordi- 
nary plan  of  bringing  a  flap  with  a  broad  pedicle,  either  by 
sliding  or  twisting,  into  the  gap  seems  likely,  on  account 
of  the  uncertainty  of  its  results,  to  give  way  in  many  cases 
to  the  method  (first  introduced  into  our  country  by  Dr. 
Wolfe)  of  transplanting  from  a  distant  part  a  piece  of  skin 
large  enough  to  fill  the  gap  without  a  pedicle.  Where 
there  is  extensive  destruction  of  skin  (group  3),  this  method 
seems  particularly  valuable.  The  important  points  are  to 
make  the  flap  considerably  larger  than  the  deficiency  it  is 
to  supply,  to  clean  the  under  surface  of  the  flap  very 
thoroughly  of  all  subcutaneous  tissue,  to  unite  it  by  fine 
sutures,  and  apply  warm  dressings. 

8.  Ptosis  (chiefly  the  congenital  form)  may  be  treated 
by  the  removal  of  an  oval  of  skin  from  the  upper  lid  paral- 
lel to  its  length,  the  muscle  not  being  touched.     Sutures 
are  to  be  carefully  inserted,  and  every  effort  made  to  get 
immediate  union,  so  as  to  avoid  a  scar. 

9.  Canthoplasty. — An  operation  for  lengthening  the  pal- 
pebral  fissure  at  the  outer  canthus.     The  cauthus  is  divided 
by  scissors  or  a  bistoury  down  to  the  rim  of  the  orbit.     The 
contiguous  ocular  conjunctiva  is  then  attached  by  sutures 
to  the  cut  edges  of  the  skin,  so  as  to  prevent  reunion,  one 
suture  being  placed  in  the  angle  of  the  wound,  one  above, 
and  one  below. 

10.  Peritomy,    for   obstinate   cases   of  partial   pannus. 
Ansesthesia  is  necessary.     Instruments:     Speculum  (Fig. 
115),  fixation  forceps  (Fig.  117),  scissors,  and  Beer's  knife 
(Fig.  135).     With  the  knife  a  circular  incision  is  carried 
through  the  conjunctiva  round  the  cornea  at  5  mm.  (£")> 
or  less,  from  its  border.     The  zone  of  conjunctiva  so  in- 
cluded, together  with  the  whole  of  its  subconjunctival  tissue 
down  to  the  sclerotic,  is  now  carefully  removed  by  snipping 
with  the  scissors.     The  surface,  being  left  to  heal,  granu- 
lates and  contracts,  and  finally  a  narrow  band  of  white 
scar-tissue  is  left,  which  obliterates  the  vessels  running  to 


LACHRYMAL     APPARATUS.  341 

the  cornea  and  prevents  the  formation  of  new  ones.  The 
subconjunctival  fascia  is  often  found  much  thickened  in 
these  cases.  Care  must  be  taken  not  to  make  the  incision 
too  far  from  the  cornea,  lest  the  insertions  of  the  recti  be 
damaged.  The  zone  of  tissue  should  be  removed  in  one 
piece.  The  symptoms  are  generally  made  worse  for  a 
time,  and  the  final  result  is  not  reached  for 
several  months.  In  some  cases  the  operation 
has,  in  my  experience,  been  very  successful, 
whilst  in  others,  without  apparent  reason,  it 
has  quite  failed  in  its  purpose,  the  cure  of  the 
pannus. 

B.  OPERATIONS  ox  THE  LACHRYMAL 
APPARATUS. 

1.  Lachrymal  abscess.     (See  p.  92). 

2.  Slitting  up  the  lower  canaliculus. — This 

is  best  done  by  means  of  a  knife  with  a  blunt     ,_• 
or  probe  point,  and  a  blade  narrow  enough  to     "~| 
enter  the  punctum.     The  best  forms  of  these     £ 
knives   are  Weber's  knife  with  a  probe  end 
(Fig.  112);    Bowman's,  with  nearly  parallel 

FIG.  112. 


Weber's  canaliculus  knife. 

borders  and  a  rounded  end  (Fig.  113),  and 
Liebreich's  (Fig.  114).  Position  as  for  1.  (1) 
the  lower  lid  is  drawn  tightly  outwards  and 
downwards  by  the  thumb.  (2)  The  canalicu- 
lus knife  is  passed  vertically  into  the  punctum,  and  then 
turned  horizontally  and  passed  on  through  the  neck  of  the 

29* 


342  OPERATIONS. 

canaliculus  till  it  reaches  the  bony  (inner)  wall  of  the  lach- 
rymal sac.  It  is  then  raised  up  from  heel  towards  point, 
and  thus  made  to  divide  the  canaliculus,  care  being  taken 
that  the  neck  is  freely  divided.  Liebreich's  knife  cuts  ita 

FIG.  113. 


Bowman's  canaliculus  knife. 
FIG.  114. 


Liebreich's  knife  for  canaliculus  and  nasal  duct. 

own  way  without  being  raised.  The  lower  canaliculus  may 
also  be  divided  with  a  Beer's  knife  (Fig.  135),  which  is  run 
along  a  fine  grooved  director  (Fig.  Ill),  previously  intro- 
duced. In  cases  of  mucocele  it  is  good  practice  to  divide 
the  wall  of  the  sac  freely,  and  to  divide  the  upper  canali- 
culus. 

3.  Catheterism  of  the  nasal  duct. — After  dividing  the 
canaliculus,  pass  a  No.  6  Bowman's  lachrymal  probe  hori- 
zontally along  its  floor  until  it  strikes  the  inner  bony  wall 
of  the  sac.     Then  raise  it  to  the   vertical  position,  and 
push  it  steadily  down  the  duct  (downwards  and  a  little 
outwards   and   backwards)  till  the  floor  of  the  nose  is 
reached.     Bowman's  earlier  probes  were  in  six  sizes,  of 
which  the  largest  was  2V-h  ^n<  in  diameter.     Mr.  Bowman 
afterwards  adopted  much  larger  probes  with  bulbous  ends; 
and  several  such  patterns  are  now  in  use.    The  probe  used 
should  be  the  largest  that  will  pass  easily. 

4.  A  stricture  of  the  duct  may  be  incised  with  any  of 
the  canaliculus  knives,  although  Weber's  and  Bowman's 
are  too  slender  to  be  used  with  safety.     Liebreich's  is  in- 
tended to  be  so  used,  and  a  special  knife  for  the  purpose  had 


STKABISMUS.  343 

previously  been  introduced  by  Stilling.  The  knife  is  used 
as  a  probe,  being  pushed  quite  down  the  duct,  then  partly 
•withdrawn  and  turned  in  other  directions,  and  pushed 
down  again.  There  is  generally  bleeding  from  the  nose. 

In  all  these  procedures  it  is  essential  to  be  certain  that 
the  probe  or  knife  rests  against  the  bony  (nasal)  wall  of 
the  lachrymal  sac  before  it  is  raised  into  the  vertical  direc- 
tion. If  the  probe  be  stopped  at  the  entrance  of  the 
canaliculus  into  the  sac  (as  may  easily  happen  if  the  canal 
be  not  thoroughly  slit  in  its  whole  length),  the  lid  will  be 
pulled  upon  and  puckered  whenever  the  instrument  is 
pushed  towards  the  nose ;  but  if  the  probe  has  reached 
the  sac,  backward  and  forward  movements  will  not  usually 
cause  puckering  of  the  lid.  If  in  the  former  case  the 
instrument  be  turned  up,  and  an  attempt  made  to  pass  it 
down  the  duct,  a  false  passage  will  be  made. 

The  direction  of  the  two  nasal  ducts  is  either  parallel 
or  such  that  if  prolonged  upwards  they  would  converge 
slightly ;  they  very  seldom  diverge.  The  probe  when  in 
the  duct  should,  even  if,  as  usual,  its  lower  end  be  curved 
forwards,  rest  against  and  indent  the  eyebrow  ;  if  it  stands 
forwards  from  the  brow  it  is  usually  in  a  false  passage. 

6.  Abscess  of  the  lachrymal  gland  or  of  the  orbit  (pp. 
89  and  159). 

C.  OPERATIONS  FOR  STRABISMUS. 

Tenotomy. — The  object  is  to  divide  the  tendon  close  to  its 
insertion  into  the  sclerotic.  In  this  country  the  operation 
is  usually  done  subconjunctivally,  but  in  the  operations  of 
Graefe  and  Snellen  the  tendon  is  more  or  less  exposed  to 
view.  The  internal  and  external  recti  are  the  only  ten- 
dons commonly  divided,  and  the  internal  by  far  the  more 
frequently.  Anaesthesia  is  seldom  necessary  except  for 
children.  Position  recumbent.  The  operator  usually 


344  OPERATIONS. 

stands  on  the  patient's  right  side  for  whichever  eye  is  to 
be  operated  on,  but  some  prefer  to  stand  behind  and  use 
curved  scissors.  Instruments:  Stop  speculum  (Fig.  115 
shows  a  convenient  and  common  pattern),  straight  scissors, 

FIG.  115. 


Stop-spring  speculum. 


with  blunted  points  (Fig.  116),  toothed  fixation  forceps 
(Fig.  117),  strabismus  hook  (Fig.  118).  There  are  several 
patterns  of  hooks,  differing  in  the  length  and  sharpness  of 
the  curve,  and  in  the  form  of  the  tip.  In  some  the  tip  is 
slightly  bulbous ;  in  others  the  hook  is  flattened  sideways, 
but  not  enlarged  at  the  end.  I  prefer  such  a  flattened 
hook. 

OPERATIONS.  Critchetfs  operation. — (1)  After  intro- 
ducing the  speculum  take  the  fixation  forceps  in  the  left 
hand,  and  pinch  up  a  fold  of  conjunctiva  over  the  lower 
border  of  the  tendon  (say  of  the  right  internal  rectus)  at 
its  insertion.  With  the  scissors  make  a  small  opening  in 
this  fold  close  to  the  forceps  end,  the  cut  being  made  in  the 
direction  of  the  caruncle.  The  capsule  of  Tenon  is  now 
identified  as  a  layer  of  fascia,  which  can  be  moved  over 
the  sclerotic ;  this  fascia  is  to  be  pinched  up  and  an  open- 
ing made  in  it  corresponding  to  the  conjunctival  wound. 
By  taking  deep  hold  with  the  forceps  both  conjunctiva  and 
capsule  may  often  be  divided  at  one  stroke,  but  with  less 
certainty  than  in  separate  stages.  As  a  rule  both  con- 


STRABISMUS. 


345 


junctiva  and  Tenon's  capsule  are  thicker  in  children  than 
in  adults. 

(2)  Take  the  hook  in  the  right  hand  (retaining  the  lip 


of  the  wound  with  the  forceps  in  the  left),  and  pass  it,  con- 
cavity downwards  and  point  backwards,  through  the  open- 


340  OPERATIONS. 

ing  in  the  capsule  as  far  as  its  elbow,  keeping  its  end  always 
flat  against  the  sclerotic.  Next  turn  the  end  of  the  hook 
upwards,  still  guided  by  the  sclerotic,  between  the  tendon 
and  the  globe  until  its  end  is  seen  projecting  beneath  the 
conjunctiva  above  the  upper  border  of  the  tendon.  On 
now  attempting  to  draw  the  hook  towards  the  cornea  it  will 
be  stopped  by  the  tendon.  If  Tenon's  capsule  have  not 
been  well  opened,  the  hook  cannot  be  passed  beneath  the 

FIG.  118. 


Strabismus  hook  (the  bent  part  is  represented  too  thin) 


tendon,  nor  swept  round  the  sclerotic.  (3)  Lay  down  the 
forceps,  transfer  the  hook  to  the  left  hand,  holding  its 
handle  parallel  with  the  side  of  the  nose,  and  tightening 
the  tendon  by  traction  forwards  and  outwards;  pass  the 
scissors,  with  the  blades  slightly  opened,  into  the  wound, 
and  push  them  straight  up  between  the  hook  and  the  eye. 
The  tendon  being  included  between  the  blades,  is  divided 
at  two  or  three  snips,  with  a  crisp  sound  and  feeling. 
When  the  whole  breadth  of  the  tendon  is  divided  the  hook 
slips  forwards  beneath  the  conjunctiva  up  to  the  edge  of 
the  cornea.  It  is  well  by  reintroducing  the  hook  to  make 
sure  that  no  small  strands  of  the  tendon  have  escaped,  for 
the  operation  does  not  succeed  unless  the  division  be  quite 
complete. 

The  effect  of  the  tenotomy  may,  if  necessary,  be  increased 
by  tying  the  eye  out;  a  stout  suture  is  passed  through  the 
conjunctiva,  embracing  about  a  quarter  of  an  inch,  close  to 
the  outer  border  of  the  cornea,  and  the  eye  being  drawn 
outwards,  the  two  ends  of  the  thread  are  firmly  attached 
by  strapping  to  the  skin  of  the  temple,  and  left  for  two  days. 

No  after-treatment  is  needed,  but  the  patient  is  more 


STRABISMUS.  347 

comfortable  if  the  eye  be  tied  up  for  a  few  hours.  If  there 
be  much  conjunctival  bleeding  (as  is  common  when  no  an- 
aesthetic is  used),  a  second  small  hole  may  be  cut  in  the 
conjunctiva  over  the  upper  border  of  the  tendon,  to  let  the 
blood  escape. 

The  difficulties  for  beginners  are — (1)  to  be  sure  of  open- 
ing Tenon's  capsule;  (2)  to  avoid  pushing  the  tendon  in 
front  of  the  scissors,  especially  when  only  the  upper  part 
remains  undivided. 

Division  of  one  internal  rectus  by  this  operation  di- 
minishes the  squint  by  about  two  lines  (4  mm.). 

After  the  operation  just  described  the  tendon,  in  retract- 
ing, draws  with  it,  to  a  varying  extent,  the  neighboring 
parts  of  Tenon's  capsule  and  the  conjunctiva,  and  these  in- 
direct but  wide  attachments,  on  their  part,  prevent  the 
tendon  from  retracting  fully,  and  hence  the  maximum 
effect  of  its  division  is  not  obtained ;  moreover,  the  caruncle 
is  drawn  back  by  the  retreating  tendon,  and  a  hollowness 
at  the  inner  canthus  results;  this  is,  however,  very  slight 
if  the  operation  wound  be  made  small,  and  as  near  as  pos- 
sible to  the  cornea.  To  avoid  this  deformity,  and  at  the 
same  time  increase  the  effect,  the  following  modification 
was  introduced  by  Mr.  Liebreich. 

Liebreich's  operation. — After  making  the  conjunctival 
wound  as  above,  the  scissors  are  passed  between  the  con- 
junctiva and  Tenon's  capsule,  and  by  repeated  horizontal 
snips  are  made  to  separate  these  membranes  freely  from 
one  another  over  the  tendon,  as  far  as  the  caruncle.  The 
capsule  is  then  opened  and  the  tendon  divided  as  in  the 
former  operation.  The  conjunctival  wound  is  closed  by  a 
suture.  This  operation  has  considerably  more  effect  than 
Critchett's  operation,  often  with  less  deformity.  But  in 
some  cases  the  deformity  is  extreme. 

The  immediate  effect  of  the  tenotomy  of  a  rectus  muscle 
is  somewhat  lessened  after  a  few  days  by  the  reunion  of  the 


348  OPERATIONS. 

tendon  with  the  sclerotic,  but  after  a  few  weeks  or  months 
it  is  again  increased  by  the  stretching  of  this  new  tissue 
(final  stage). 

Readjustment  or  Advancement  consists  in  bringing  for- 
wards to  a  new  attachment  the  tendon  of  a  rectus  (gener- 
ally the  internal,  occasionally  the  external),  which  has  be- 
come attached  too  far  back  after  a  previous  tenotomy  or 
has  become  weakened,  e.  g.,  in  myopia.  There  are  several 
different  operations,  but  in  nearly  all  of  them  the  tendon 
is  held  in  its  new  position  by  sutures.  The  operation  is 
tedious  and  painful,  and  the  patient  must  always  be  under  an 
anaesthetic.  The  instruments  are  the  same  as  for  tenotomy. 

I  generally  perform  the  operation  as  follows  (essentially 
by  Critchett's  method) :  A  vertical  incision  is  made  about 
4  mm.  from  the  cornea,  exposing  the  whole  width  of  the 
tendon,  but  the  conjunctiva  is  not  extensively  dissected  up 
from  it.  The  tendon  is  then  divided  on  a  hook  in  the  usual 
way.  Three  double-needled  sutures  are  then  passed  from 
within  outwards  through  the  flap  formed  by  the  tendon, 
fascia,  and  conjunctiva,  at  a  considerable  distance  from  its 
free  edge,  and  the  flap  then  shortened  by  cutting  off  its 
free  border.  The  deep  ends  of  the  sutures  are  next  passed, 
by  means  of  their  remaining  needles,  from  within  outwards 
through  fascia  and  conjunctiva,  close  to  the  border  of  the 
cornea,  taking  as  broad  a  hold  as  possible.  At  this  stage 
the  external  rectus  is  to  be  divided  and  a  stout  traction 
suture  introduced  at  the  outer  side  of  the  eye  (see  preceding 
page),  by  which  it  can  be  drawn  in.  The  three  tendon 
sutures  are  now  tied  and  the  eye  rolled  in,  and  kept  as  far 
inwards  as  possible  by  fastening  the  traction  suture  to  the 
bridge  of  the  nose  with  strapping.  The  traction  suture 
cuts  out  in  two  or  three  days ;  the  tendon  sutures  should 
be  left  in  a  week.  The  pain  and  swelling,  which  for  a  few 
days  are  sometimes  considerable,  are  best  relieved  by  ap- 


EXCISION     OF     THE     EYE.  349 

plication  of  ice  or  a  spirit  lotion  to  the  lids.     The  final 
result  is  not  reached  for  several  weeks  (p.  323). 

D.  EXCISION  OF  THE  EYE. 

Instruments  as  for  squint,  but  the  scissors  curved  on  the 
flat.  The  operator  may  stand  either  behind  or  in  front. 
(1)  Divide  the  ocular  conjunctiva  all  round  close  to  the 
cornea,  but  leave,  at  one  side,  enough  to  hold  by  with  the 
forceps.  (2)  Open  Tenon's  capsule  and  divide  each  rectus 
tendon  and  the  neighboring  fascia  on  the  hook ;  the  two 
obliques  are  seldom  divided  on  the  hook.  (3)  Make  the 
eye  start  forwards  by  pressing  the  speculum  back  behind 
the  equator  of  the  globe.  (4)  Pass  the  scissors  backwards 
along  the  sclerotic  till  their  open  blades  can  be  felt  to  em- 
brace the  optic  nerve  (recognized  by  its  toughness  and 
thickness),  and  divide  it  by  a  single  cut  while  steadying 
the  globe  with  a  finger  of  the  other  hand.  Finish  by 
dividing  the  oblique  muscles  and  remaining  soft  parts  close 
to  the  globe.  Apply  pressure  for  a  minute  or  two,  and 
then  tie  up  tightly  for  six  or  eight  hours  with  an  elastic 
pad  of  small  sponges  overlaid  by  cotton  wool.  There  is 
scarcely  ever  serious  bleeding.  The  artificial  eye  may  be 
fitted  in  from  two  to  three  weeks.1 

After  some  weeks  or  months  a  button  of  granulation 
tissue  occasionally  grows  from  the  scar  at  the  bottom  of  the 
conjunctiva!  sac,  and  should  be  snipped  off*. 

The  operation  is  more  difficult  when  the  eye  is  ruptured 
or  shrunken,  or  the  surrounding  parts  much  inflamed  and 
adherent.  The  order  of  division  of  the  muscles  is  quite 

1  The  glass  eye  must  be  renewed  as  often  as  it  gets  rough,  gen- 
erally at  least  once  a  year.  Some  persons  have  much  difficulty  in 
tolerating  it,  and  they  must  be  content  to  wear  it  for  only  a  part 
of  the  day.  It  is  always  to  be  removed  at  bed-time. 

30 


350  OPERATIONS. 

immaterial.  The  important  points  are  to  leave  as  much 
conjunctiva  as  possible,  so  as  to  form  a  deep  bed  for  the 
glass  eye,  and  by  keeping  the  scissors  close  to  the  globe 
during  the  whole  operation,  to  avoid  unnecessary  laceration 
of  the  tissues. 

"When,  as  in  some  cases  of  intraocular  tumor,  it  is  desired 
to  remove  another  piece  of  the  optic  nerve,  the  nerve 
be  felt  for  with  the  finger,  seized  and  drawn  forward  with 
the  forceps,  and  cut  off  further  back  with  the  scissors. 

Abscission  is  the  removal  of  a  staphylomatous  cornea 
with  the  front  part  of  the  sclerotic,  leaving  the  hinder  part 
of  the  globe  with  the  muscles  attached,  to  serve  as  a  mova- 
ble stump  for  carrying  the  artificial  eye.  Four  or  five 
semicircular  needles  carrying  sutures  are  made  to  puncture 
and  counter-puncture  the  sclerotic  just  in  front  of  the  at- 
tachments of  the  recti;  the  part  of  the  globe  in  front  of 
the  needles  is  cut  off,  the  needles  drawn  through,  and  the 
sutures  tied.  The  operation  is  admissible  only  when  the 
ciliary  region  is  free  from  disease,  and  has,  therefore,  a  very 
limited  application;  even  in  the  most  favorable  cases  the 
stump  is  not  entirely  free  from  the  risk  of  setting  up  sym- 
pathetic inflammation.  It  is  said  that  if  the  sutures  are 
passed  only  through  the  conjunctiva  or  the  muscles,  the 
risk  is  less  than  when  they  are  passed  through  the  sclerotic. 

The  recently  revived  operation  of  optico-tiliary  neurotomy, 
in  which  the  optic  nerve  and  all  the  ciliary  nerves  are 
divided  without  removal  of  the  globe,  with  the  view  of 
preventing  sympathetic  disease  appears  to  me  to  be  bad 
surgery.  The  sensibility  of  the  cornea,  abolished  by  the 
operation,  often  returns,  proving  that  the  ciliary  nerves 
have  reunited.  The  cut  ends  of  the  optic  nerve  have  also 
been  found  reunited.  The  operation,  therefore,  cannot  be 
relied  upon  to  destroy  these,  nor,  it  may  be  added,  any  of 
the  other  possible  paths  (p.  152)  along  which  sympathetic 
irritation  and  inflammation  may  travel. 


CORNEA.  351 


E.  OPERATIONS  ON  TELE  CORNEA. 

Removal  of  foreign  bodies. — Position  as  for  1.  Instru- 
ments :  a  steel  spud  (Fig.  119),  or  a  broad  needle  with 
double  cutting  edge  (Fig.  120).  The  eyelids  are  held  open 
by  the  index  and  ring  fingers,  and  the  eyeball  steadied 
by  the  middle  finger  placed  against  the  temporal  side  of 
the  globe.  The  chip  is  gently  picked  or  tilted  off  by 
placing  the  edge  of  the  spud  beneath  it,  or,  if  firmly  em- 
bedded, a  certain  amount  of  scraping  may  be  necessary. 
The  first  few  touches,  by  which  the  epithelium  is  removed, 
cause  the  most  pain.  If  the  foreign  body  be  barely  em- 

FIG.  119.  FIG.  120. 


Corneal  spud.  Broad  needle. 

bedded  in  the  epithelium,  a  touch  with  a  little  roll  of 
blotting  paper  will  often  detach  it.  When  a  fragment  of 
iron  has  been  present  for  more  than  a  couple  of  days,  its 
corneal  bed  is  usually  stained  by  rust,  and  a  little  plate  or 
ring  of  brown  corneal  slough  can  often  be  picked  off  after 
the  removal  of  the  chip ;  but,  as  a  rule,  this  minute  slough 
may  be  left  to  separate  spontaneously. 

AFTER-TREATMENT. — The  protection  of  the  corneal  sur- 
face from  friction  and  irritation  by  keeping  the  eye  tied 
up  is  generally  sufficient ;  a  drop  or  two  of  castor  oil 
placed  in  the  conjunctival  sac  lubricates  the  cornea  and 
lessens  the  irritation.  Atropine  is  to  be  used  if  there  be 
marked  congestion  and  photophobia. 

When  a  splinter  is  deeply  and  firmly  embedded,  especi- 
ally if  it  has  penetrated  the  cornea  and  projects  into  the 
anterior  chamber,  the  operation  is  much  more  difficult, 
and  is  no  longer  a  "  minor "  one.  Unless  great  care  be 
taken  the  splinter  in  such  a  case  may  be  pushed  on  into 


352  OPERATIONS, 

the  chamber,  and  the  iris  or  lens  be  wounded.  This  may 
sometimes  be  prevented  by  passing  a  broad  needle  through 
the  cornea  at  another  part  and  laying  it  against  the  inner 
surface  of  the  wound,  so  as  to  form  a  guard  or  foil  to  the 
foreign  body,  the  latter  being  removed  by  spud  or  forceps 
from,  the  front. 

A  foreign  body  in  the  anterior  chamber  should,  in  re- 
cent cases,  always  be  removed,  and  the  piece  of  iris  on 
which  it  lies  must  generally  be  excised.  In  cases  of  old 
standing  we  may  judge  by  the  symptoms  whether  to  oper- 
ate or  not. 

Paracentesis  of  the  anterior  chamber. — Position  as  for  1 
or  recumbent ;  anaesthesia  seldom  necessary.  Instruments : 
a  paracentesis  needle  (Fig.  121)  with  a  very  small,  short, 

FIG.  121. 


Paracentesis  needle  and  probe  mounted  on  same  handle. 

triangular  blade  bent  at  an  obtuse  angle  (like  a  minute 
bent  keratome),  or  a  broad  needle  (Fig.  120).  The  former 
is  more  safe,  as  the  blade  is  too  short  to  reach  the  iris  or 
lens,  even  if  the  patient  should  jerk  his  head.  If  the  con- 
tents of  the  chamber  do  not  follow  the  needle  on  its  with- 
drawal, a  small  probe  (Fig.  121)  is  passed  into  the  wound. 
In  cases  where  the  operation  needs  repetition  every  day  the 
original  wound  can  be  reopened  with  the  probe,  but  if  more 
than  two  days  elapse  a  fresh  puncture  is  necessary.  Spec- 
ulum and  fixation  forceps  should  be  used  unless  the  patient 
has  good  self-control. 

Corneal  section  for  hypopyon  ulcer. — Position  recum- 
bent. Anaesthesia  not  usually  needed.  Instruments :  a 
Graefe's  or  Beer's  cataract  knife  (Figs.  129  and  135), 
speculum  and  fixation  forceps.  The  incision  is  carried 
through  the  whole  thickness  of  the  cornea  from  one  side 


CORNEA.  353 

of  the  ulcer  to  the  other,  being  both  begun  and  finished  in 
sound  tissue.  Or  it  may  be  placed  entirely  in  sound  cornea 
or  at  the  sclero-corneal  junction  (p.  123),  leaving  the  ulcer 
untouched. 

The  knife  is  entered  at  an  angle  with  the  plane  of  the 
iris,  its  edge  straight  forwards ;  when  its  point  is  seen  or 
judged  to  have  perforated  the  cornea,  the  handle  is  de- 
pressed until  the  back  of  the  knife  lies  parallel  with  the 
iris,  and  the  blade  then  pushed  straight  across  the  ulcer  to 
the  point  chosen  for  counter-puncture ;  or  more  often  in 
practice  it  is  just  pushed  on  till  it  cuts  its  way  out.  The 
aqueous  ought  not  to  escape  until  the  point  of  the  knife  is 
engaged  in  its  counter-puncture,  but  an  earlier  escape  can- 
not always  be  avoided.  Notwithstanding  the  apparent 
risk  to  the  iris  and  lens,  accidents  seldom  happen  if  the 
back  of  the  knife  be  carefully  kept  parallel  to  them,  or  the 
point  even  directed  a  little  forwards.  If  it  is  desired  to 
keep  the  wound  open,  its  edges  are  to  be  separated  by  a 
probe  every  second  or  third  day.  The  wound  closes  quickly 
at  first,  unless  kept  open,  but  after  having  been  opened  a 
few  times,  it  sometimes  remains  patent  for  longer. 

Operations  for  conical  cornea. — The  object  is  to  produce 
a  scar  at  the  apex  of  the  cone,  which  by  contracting  shall 
reduce  the  curvature,  and  so  diminish  the  high  degree  of 
irregular  myopic  astigmatism  to  which  the  condition  gives 
rise. 

There  are  three  methods.  (1)  Graefe's  operation  consists 
in  first  carefully  shaving  off  the  apex  of  the  cone  without 
entering  the  anterior  chamber,  and  then  applying  solid 
mitigated  nitrate  of  silver  to  the  raw  surface,  the  resulting 
ulceration  being  followed  by  some  scarring.  The  applica- 
tion needs  great  care,  and  the  after-treatment  is  trouble- 
some, as  there  is  the  risk  that  more  inflammation  than  is 
wished  for  may  set  in.  (2)  In  another  operation  the  apex 
of  the  cone  is  cut  off  with  a  cataract-knife,  the  anterior 

30* 


354  OPERATIONS. 

chamber  being  entered,  and  the  wound  either  left  to  close 
or  united  by  sutures.  There  are  several  different  modes  of 
removing  the  little  piece  of  cornea.  (3)  Mr.  Bowman  re- 
moves the  outer  layers  of  the  cone  by  means  of  a  very 
delicate  cutting  trephine,  and  leaves  the  surface  to  heal 
and  contract.  I  believe  that  No.  2  gives  on  the  whole  the 
best  results. 

AFTER-TREATMENT. — Atropine  and  compressive  bandage 
until  the  wound  has  closed  ;  antiphlogistic  treatment,  and 
heat  locally,  if  inflammatory  symptoms  arise. 
•  All  operations  for  conical  cornea  are  difficult  to  perform 
and  somewhat  uncertain  in  result,  but  in  many  cases  vision 
improves  from  barely  seeing  very  large  letters  before  opera- 
tion to  reading  small  print  afterwards.  Th,e  final  result  is 
never  gained  for  several  months.  An  artificial  pupil  is 
often  necessary  if  the  corneal  opacity  remains  finally  large 
enough  to  obstruct  the  light. 

F.  OPERATIONS  ON  THE  IRIS. 

A  portion  of  the  iris  is  very  often  removed  by  operation 
(iridectomy),  and  with  various  objects.  The  principal  of 
these  are — (1)  the  direct  improvement  of  sight  by  altering 
the  position  and  size  of  the  pupil  (artificial  pupil) ;  (2)  to 
influence  the  course  of  an  active  disease — glaucoma,  iritis, 
ulcer  of  cornea  with  hypopyon  ;  (3)  to  remove  the  risks  at- 
tending "exclusion"  and  "occlusion"  of  the  pupil,  by  re- 
storing communication  between  the  anterior  and  posterior 
chambers ;  (4)  as  a  stage  in  the  extraction  of  cataract. 

Artificial  pupil. — The  object  is  to  remove  the  portion  of 
iris  in  the  position  best  adapted  to  sight ;  thus  in  cases  of 
leucoma  the  iridectomy  is  made  opposite  the  clearest  part 
of  the  cornea.  When  the  state  of  the  cornea  allows  it,  the 
new  pupil  should  be  made  down-inwards  or  straight  down- 
wards ;  the  next  best  place  is  outward  or  out-upward,  and 
straight  upwards  is,  of  course,  least  useful,  because  the  new 


IRIS.  355 

pupil  will  be  covered  by  the  lid.  The  coloboma  should 
generally  be  small,  and  often  only  the  inner  (pupillary) 
part  of  the  chosen  portion  is  to  be  removed,  the  outer 
(ciliary)  part  being  left  (Fig.  122)  so  as  to  prevent  the 

FIG.  122. 


Iridectomy  downwards  for  artificial  pupil.     Line  of  incision  is  intended 
for  extraction  of  cataract.     (Wecker.) 

light  from  passing  through  the  margin  of  the  lens.  After 
such  an  operation  the  pupil  will  be  oval  or  pear-shaped, 
and  widest  towards  the  centre.  The  incision  should  lie  in 
the  cornea!  tissue,  if  only  the  pupillary  part  of  the  iris  is 
to  be  removed ;  but  if  only  a  narrow  zone  of  cornea  remain 
clear,  the  incision  must  lie  a  little  outside  the  sclero-corneal 
junction,  lest  its  scar  should  interfere  with  the  transparency 
of  the  remaining  clear  cornea.  The  loop  of  iris  should  be 
cut  off  with  a  single  snip. 

In  Iridectomy  for  glaucoma  the  coloboma  is  to  be  large, 
the  iris  to  be  removed  quite  up  to  its  ciliary  attachment, 

FIG.  123. 


Iridectomy  for  glaucoma  (from  Wecker). 

and  the  incision  to  lie  as  far  back  in  the  sclerotic  as  possi- 
ble (1  to  2  mm.  from  the  border  of  the  cornea  is  not  too 
far).  The  sides  of  the  coloboma  should  be  parallel,  or 
wider  towards  the  incision  than  towards  the  pupil  ("key- 
hole pupil")  (Fig.  123).  The  loop  of  iris,  when  drawn 


356  OPERATIONS. 

out,  is  usually  cut  first  in  one  angle  of  the  wound,  then  torn 
from  its  ciliary  attachment  by  carefully  drawing  it  over  to 
the  other  angle  of  the  wound,  and  its  other  end  then  cut, 
the  points  of  the  scissors  being  pushed  just  within  the  lips 
of  the  wound  to  ensure  removal  of  the  largest  possible 
portion. 

The  difficulty  of  making  an  artificial  pupil  (for  optical 
purposes)  of  the  best  shape,  i.  e.,  broad  towards  the  natural 
pupil  and  narrow  towards  the  circumference,  is,  owing  to 
the  small  size  of  the  parts,  much  greater  than  would  be  at 
first  supposed,  and  several  methods  are  in  use.  In  Mr. 
Critchett's  iridodesis  the  loop  of  iris  is  drawn  out  through 
a  small  opening,  and  strangulated  by  a  fine  ligature  tied 
round  it  just  over  the  incision ;  the  little  loop  soon  drops 
off",  and  the  result  is  a  pear-shaped  pupil,  with  its  broad 
end  towards  the  centre.  The  inclusion  of  iris  in  the  track 
of  the  wound  has  sometimes  set  up  severe  irritation,  and 
even  destructive  irido-cyclitis,  and  on  this  account  the 
operation  is  now  but  seldom  performed.  Another  plan  is 
to  draw  out  a  small  loop  of  iris  with  a  blunt  hook  (TyrelPs 
hook),  and  to  cut  off  only  the  pupillary  portion ;  this 
method  is  uncertain,  but,  on  the  whole,  it  gives  good  results. 
Mr.  Carter  cuts  out  a  V-shaped  bit  of  iris  by  introducing 
a  pair  of  blunt-ended  iridotomy  scissors  through  the  corneal 
incision,  opening  the  blades,  and  cutting  out  just  as  much 
iris  as  is  intruded  between  them  by  the  gush  of  the  escaping 
aqueous.  This  operation  requires  much  nicety,  and  entails 
some  risk  of  wounding  the  lens,  but  when  well  performed 
it  gives  an  excellent  artificial  pupil. 

Iridotomy  (iritomy).  —  In  this  operation  an  artificial 
pupil  is  formed  by  the  natural  gaping  of  a  simple  incision 
in  the  iris,  or  by  making  a  V-shaped  incision  and  allowing 
the  tongue-shaped  piece  to  retract.  It  is  only  applicable 
when  the  lens  is  absent.  Through  a  small  incision  in  the 
cornea,  between  the  centre  and  margin,  the  scissors  (shears) 


IRIS. 


357 


FIG.  124. 


shown  at  Fig.  124  are  passed;  the  more  pointed  blade  is 
passed  behind  the  iris  as  far  as  is  deemed  necessary,  and 
the  iris  and  false  membrane  divided  by  a  single  closure  of 
the  blades.  It  is  sometimes  necessary  to  make  a  second 
cut  at  an  angle  with  the  first,  so  as  to 
include  a  V-shaped  tongue  of  iris 
which  will  shrink  and  allow  a  larger 
pupil. 

Iridotomy  is  most  useful  when  the 
iris  has  become  tightly  drawn  towards 
the  operation  scar  by  iritis  occurring 
after  cataract  extraction  (Fig.  136). 
The  line  of  the  cut  in  the  iris  should 
lie  as  nearly  as  may  be  across  the 
direction  of  its  fibres,  and  should 
always  be^as  long  as  possible.  In 
cases  of  this  sort,  or  when  without 
much  dragging  of  the  iris  towards 
the  scar,  the  pupil  is  filled  by  iritic 
or  cyclitic  membrane  after  cataract 
extraction,  iridotomy  yields  a  better 
pupil  than  iridectomy,  and  with  less 
disturbance  of,  and  no  dragging  upon, 
the  ciliary  body. 

The  operation  of  iridectomy.  Po- 
sition recumbent ;  the  operator  usually 
stands  behind.  Anaesthesia  is  always 
strongly  advisable,  though  in  urgent 
cases  iridectomy  can  be  successfully 
performed  by  an  adept  without  it. 
Instruments:  stop  speculum  (Fig. 
115),  fixation  forceps,  bent  keratome 
(Fig.  125),  iris  forceps  bent  at  various 
angles,  according  to  the  position  of  the  iridectomy  (Fig.  127), 
iris  scissors  with  elbow  bend  (Fig.  126),  of  which  some  pat- 


Iridotomy  scissors. 


358  OPERATIONS. 

terns  have  one  or  both  blades  probe-pointed,  a  curette 
(Fig.  131)  for  replacing  the  cut  ends  of  the  iris  and  pre- 
venting their  incarceration  in  the  angles  of  the  wound. 
The  iridotomy  scissors  (Fig.  124)  are  very  convenient, 
especially  for  downward  and  inward  operations,  and  for 
the  left  hand.  A  Graefe's  cataract  knife  (Fig.  129)  may 
be  used  if  the  anterior  chamber  be  very  shallow. 

The  conjunctiva  is  held  by  the  fixation  forceps  near  the 
cornea  at  a  point  opposite  to  the  place  selected  for  punct- 
ure. (1)  The  keratome  is  to  be  entered  slowly,  steadily 
pushed  on  across  the  anterior  chamber  till  the  wound  is  of 
the  desired  size,  then  slowly  withdrawn,  and  in  its  course 
carefully  rotated  to  one  side,  so  as  to  lengthen  the  internal 
wound.  Two  points  need  attention  in  making  the  incision : 
as  soon  as  the  point  of  the  knife  is  visible  in  the  anterior 

FIG.  125. 


Bent  triangular  keratome. 

chamber  it  must  be  tilted  slightly  forwards  to  avoid  wound- 
ing the  iris  and  lens ;  and  care  must  be  taken  not  to  tilt  it 
sideways,  for  by  so  doing  the  wound  instead  of  lying  par- 
allel with  the  border  of  the  cornea  will  lie  more  or  less 
across  it.  The  incision  is  made  almost  as  much  by  lifting 
the  eye  against  the  knife  with  the  fixation  forceps,  as  by 
pushing  the  knife  against  the  eye.  The  fixation  forceps 
are  now  laid  down,  or  if  fixation  be  still  necessary,  they 
are  given  to  an  assistant,  who  is  to  gently  draw  the  eye 
into  the  position  required  for  the  next  step ;  in  so  doing  he 
is  to  draw  away  from  the  eye,  not  to  push  the  ends  of  the 
forceps  against  the  sclerotic.  (2)  The  iris  forceps  are  in- 
troduced, closed,  into  the  wound  and  passed  very  nearly 
to  the  pupillary  border  of  the  iris,  before  being  opened 


IRIS. 


359 


and  made  to  grasp  it.  Ey  seizing  the  pupillary  part  of  the 
iris  its  inner  circle  is  certain  to  be  brought  outside  the 
wound,  when  the  forceps  are  now  withdrawn  ;  if  the  iris  be 
seized  in  the  middle  of  its  breadth,  a  button-hole  may  be 


cut  out  and  the  pupillary  part  left  standing.  Often  the 
iris  is  carried  into  the  wound  by  the  gush  of  aqueous  as 
the  keratome  is  withdrawn,  and  it  is  then  seized  without 
passing  the  forceps  so  far  into  the  chamber.  (3)  The  loop 
of  iris  having  been  cut  off,  either  at  a  single  snip,  or  by 


360  OPERATIONS. 

cutting  first  one  end  and  then  the  other,  as  in  glaucoma 
(p.  355),  the  tip  of  the  curette  is  gently  introduced  into 
each  angle  of  the  wound  to  free  the  iris,  should  it  be  en- 
tangled; this  little  precaution  is  of  importance  in  order  to 
prevent  inclusion  of  the  iris  in  the  track  of  the  wound. 
The  speculum  is  now  removed  and  both  eyes  bandaged 
over  a  pad  of  cotton-wool,  either  with  a  four-tailed  bandage 
of  knitted  cotton,  or  two  or  three  turns  of  a  soft  calico  or 
flannel  roller. 

The  anterior  chamber  is  refilled  in  twenty-four  hours, 
except  in  cases  of  glaucoma,  when  the  wound  frequently 
leaks  more  or  less  for  several  days.  It  is  better  in  all 
cases  to  keep  the  eye  bandaged  for  a  week,  the  wound  being 
but  feebly  united,  and  likely  to  give  way  from  any  slight 
blow  or  other  accident.  When  the  incision  lies  in,  or 
partly  in,  the  sclerotic,  some  bleeding  generally  occurs; 
when  the  eye  is  much  congested  this  hemorrhage  is  con- 
siderable, and  the  blood  may  run  into  the  anterior  chamber 
either  during  or  after  the  excision  of  the  iris;  it  can  be 
drawn  out  by  depressing  the  lip  of  the  wound  with  the 
curette,  but  if  the  chamber  again  fills,  no  prolonged  efforts 
need  be  made,  since  the  blood  is  usually  absorbed  without 
trouble  in  a  few  days.  In  diseased,  especially  glaucoma- 
tous,  eyes  secondary  hemorrhage  sometimes  occurs  from 
the  iris  several  days  after  the  operation,  and  the  absorption 
of  this  blood  is  often  slow. 

Sclerotomy  is  an  operation  for  dividing  the  sclerotic  near 
to  the  margin  of  the  cornea.  It  is  employed  in  glaucoma 
instead  of  iridectomy,  or  after  iridectomy  has  failed.  The 
pupil  is  to  be  contracted  as  much  as  possible  by  eserine 
before  the  operation.  It  is  performed  subconjunctivally,  a 
Graefe's  cataract  knife  (Fig.  129)  being  entered  through 
the  sclerotic  near  the  margin  of  the  cornea,1  passed  in  front 

1  Wecker  makes  it  1  mm.  from  the  clear  cornea.  In  my  own 
operations  the  distance  is  generally  about  2  mm. 


IRIS.  361 

of  the  iris,  and  brought  out  at  a  corresponding  point  on  the 
other  side,  or  as  to  include  nearly  one-third  of  the  circum- 
ference ;  the  puncture  and  counter-puncture  are  then  en- 
larged by  slow  sawing  movements ;  the  central  third  of  the 

FIG.  128. 


Diagrammatic  section  of  ciliary  region,  showing  path  of  wound  in 
iridectomy  for  glaucoma  (/)  and  in  sclerotomy  (S).  (Compare  Fig.  8j, 
1  and  2.) 

sclerotic  flap,  and  the  whole  of  the  conjunctiva  (except  at 
the  punctures)  are  left  undivided.  The  knife  is  then  slowly 
withdrawn.  The  scleral  wounds  often  gape  a  little  in  the 
next  few  days.  The  whole  operation  is  to  be  done  very 
slowly  that  the  aqueous  humor  may  escape  gradually ;  any 
rush  of  fluid  is  likely  to  carry  the  iris  into  the  wound  and 
cause  a  permanent  prolapse,  and  this  is  considered  by 
nearly  all  operators  as  very  undesirable,  if  not  a  source  of 
danger.  If  decided  prolapse  occur,  the  iris  should  be  ex- 
cised, and  the  operation  then  becomes  a  very  peripheral 
iridectomy.  A  moderate  degree  of  bulging  and  separation 
of  the  lips  of  the  two  scleral  wounds  takes  place  for  a  week 
or  two,  when  the  scar  flattens  down,  and  finally  a  mere 
bluish  line  is  left.  Sclerotomy  is  difficult  to  perform  well; 
if  the  incision  be  too  long  and  too  far  back,  there  is  danger 
of  hemorrhage  into  the  vitreous  and  even  of  puckering 
and  inflammation  of  the  scar  and  sympathetic  ophthalmitis 
of  the  other  eye ;  in  other  cases  it  may  be  too  short  or  too 

31 


362  OPERATIONS. 

far  forward,  and  then  it  is  no  better  than  an  incision  for 
iridectoiny.  In  Fig.  128,  /shows  the  line  of  incision  in 
iridectomy  for  glaucoma,  and  S  the  line  in  sclerotouiy. 
Comparison  with  Fig.  84,  however,  will  show  that  the 
incisions  for  iridectomy  in  glaucoma  differ  in  position  a 
good  deal. 

G.  OPERATIONS  FOR  CATARACT. 

1.  Extraction  of  cataract  has  been  systematically  prac- 
tised for  nearly  a  century  and  a  half.  The  operation  has 
passed  through  many  important  changes,  and  many  differ- 
ent procedures  are  still  in  use.  There  is  also  much  di- 
versity of  practice  in  regard  to  anaesthesia,  but  a  large 
number  of  the  most  experienced  operators  frequently  dis- 

FIG.  129. 


Graefe's  cataract  knife. 

pense  with  it.  All  the  operations  are  difficult  to  perform 
well,  and  much  practice  is  needed  to  ensure  the  best  pros- 
pects of  success.  Further,  the  sources  of  possible  failure 

FIG.  130. 


Cataract  spoon. 

are  numerous,  and  since  in  avoiding  one  we  are  very  apt 
to  fall  into  another,  it  is  scarcely  likely  that  any  one  opera- 
tion will  in  all  its  details  ever  be  universally  adopted.  At 
present  the  majority  of  surgeons  adhere  more  or  less  closely 
to  the  operation  known  as  the  "  modified  linear "  method 
of  von  Graefe. 

All  operations  for  extraction  of  hard  cataract  agree  in 
the  following  points  :  (1)  An  incision  is  made  in  the  cornea, 


CATARACT.  363 

at  the  junction  of  the  cornea  and  sclerotic,  or  even 
slightly  in  the  sclerotic,  large  enough  to  give  passage  to 
the  crystalline  lens  without  its  being  broken 
or  altered  in  shape.  The  knife  now  almost  uni- 
versally employed  is  the  narrow,  thin,  straight 
knife  of  von  Graefe  (Fig.  129).  (2)  The  cap- 
sule is  freely  opened  with  a  small,  sharp-pointed 
instrument  (cystotome  or  pricker,  Fig.  131). 

(3)  The  lens  is  removed  through  the  rent  in 
the  capsule  (the  latter  structure  remaining  be- 
hind),  either   by   pressure   and   manipulation 
outside  the  eye,  or  by  the  introduction  of  a 
traction  instrument  (scoop  or  spoon,  Fig.  130) 
passed  behind  the  lens.     Most  operators  have 
abandoned  the  habitual  use  of  the  scoop,  reserv- 
ing it  for  certain  emergencies  and  special  cases. 

(4)  Iridectomy  is  very  often  performed  as  the 
second  stage,  not  with  the  primary  object  of     S 
facilitating  the  exit  of  the  lens,  but  to  lessen     < 
the  after-risks  of  iritis ;  since  it  has  been  found 
that,  where  no  iridectomy  is  done,  the  portion 
of  iris  traversed  by  the  lens  is  often  so  bruised 
or  stretched  as  to  become  the  starting-point  of 
severe  traumatic  iritis.     The  following  are  the 
most  important  types  of  operation  at  present 
practised. 

(a)  Linear  extraction  (best  described  here, 
though  not  applicable  to  hard  cataract).  A 
small  incision  (4  to  6  mm.)  is  made  by  a  kera- 
tome  (Fig.  125)  well  within  the  outer  margin 
of  the  cornea.  It  is  often  better,  though  not  es- 
sential, to  make  a  small  iridectomy.  After  open- 
ing the  capsule  the  lens  is  squeezed  out  piece- 
meal or  coaxed  out  by  depressing  the  outer  lip  of 
the  wound  with  the  curette  (Fig.  131).  Only  soft  cataracts  or 
those  with  a  very  small,  hard  nucleus  can  be  so  dealt  with. 


364  OPERATIONS. 

The  wish  to  extend  the  principle  of  a  straight  wound  to 
full-sized  hard  cataracts  led  von  Graefe,  in  1865,  to  intro- 
duce (5)  the  "modified  linear"  or  "peripheral  linear"  ex- 
traction, in  which  the  incision  lies  slightly  beyond  the 
sclero-corneal  junction  (Fig.  133,  2),  and  consequently  in- 
volves the  conjunctiva,  of  which  a  flap  is  made.  The 
incision  is  intended  to  form  an  arc  of  the  largest  possible 
circle,  i.  e.,  of  the  sclerotic,  not  of  the  cornea,  and  its  plane, 
therefore,  must  form  as  nearly  as  may  be  a  radius  of  the 
scleral  curve  and  lie  at  a  considerable  angle  with  that  of 
the  iris  (Fig.  134,  2).  A  large  iridectomy  is  performed  as 
the  second  stage.  The  incision  is  made  with  the  long 
narrow  knife  of  von  Graefe  (Fig.  129),  which  is  at  first 
directed  towards  the  centre  of  the  pupil  and  then  brought 
up  to  the  seat  of  counter-puncture.  The  edge  is  turned 
somewhat  forward  during  the  greater  part  of  the  proceed- 
ing, and  the  cut  completed  by  sawing  movements.  The 
iridectomy  is  occasionally  made  several  weeks  before  the 
extraction  ("preliminary  iridectomy"),  the  parts  being 
allowed  to  become  perfectly  quiet  in  the  interval.  The 
disadvantages  of  the  peripheral  linear  extraction  are,  the 
frequency  of  bleeding  from  the  conjunctiva  into  the  an- 
terior chamber,  the  parts  being  thus  obscured  ;  a  consider- 
able risk  of  loss  of  vitreous,  owing  to  the  peripheral 
position  of  the  wound,  and  sometimes  a  difficulty  in 
making  the  lens  present  well ;  a  small  but  appreciable 
risk  that  the  operated  eye  will  set  up  sympathetic  inflam- 
mation, the  wound  lying  in  the  "dangerous  region" 
(p.  152) ;  lastly,  there  is  a  tendency  to  make  the  wound 
rather  too  short  in  order  to  avoid  some  of  these  risks,  and 
thus  difficulties  are  introduced  in  the  clean  removal  of  the 
lens.  Its  great  advantage  lies  in  the  very  small  risk  of 
suppurative  inflammation. 

(c)  Short  flap  (de  Wecker). — The  incision,  made  with 
the  same  knife,  lies  exactly  at  the  sclero-corneal  junction, 


CATARACT.  365 

and  is  of  such  an  extent  that  it  has  a  height  of  about  3  mm. 
(i  of  the  diameter  of  the  cornea)  (Fig.  132).  The  iridec- 
tomy  is  small  (as  in  Fig.  122).  For  very  large  cataracts 
this  incision  is  not  quite  large  enough. 

FIG.  132. 


Short  flap. 

A  variety  of  this  operation  consists  in  placing  the  in- 
cision rather  further  down,  and  at  the  same  time  giving  it 
a  somewhat  sharper  curve,  so  that  it  forms  an  arc  of  a 
smaller  circle  than  before,  but  is  still  not  concentric  with 
the  cornea  (Fig.  133,  3,  upper  section).  The  puncture  is 

FIG.  133. 


I  2  3 

Paths  of  incisions  for  extraction  of  cataract.  1,  Old  flap;  2,  peripheral 
linear  ;  3  (upper  figure),  a  variety  of  the  peripheral  linear  ;  (lower  figure) 
corneal  section.  The  wound  appears  as  a  narrow  slit  (2)  or  a  broad 
track  (1),  when  seen  from  the  front,  according  to  the  inclination  of  its 
plane.  Compare  Fig.  134.  The  dotted  circle  shows  the  outline  of  the  lens. 

directed  somewhat  downwards  (as  at  the  right-hand  end  of 
the  figure),  and  its  plane,  which  at  the  puncture  and 
counter-puncture  is  almost  parallel  with  the  iris,  alters  to 
nearly  a  right  angle  at  the  summit  of  the  flap.  The  track 
of  the  wound,  if  shaded,  would  appear  as  in  the  figure. 

(d)  The  incision  has  nearly  the  same  curve  and  plane 
as  in  b,  but  the  greater  part  of  the  incision  lies  considerably 
within  the  margin  of  the  cornea  (corneal  section),  and 
iridectomy  is  usually  dispensed  with.  In  Liebreich's  and 

31* 


OPEKATIONS. 


Bader's  operation  the  section  is  made  downwards  and  its  * 
plane  forms  an  angle  of  about  45°  with  that  of  the  iris 
(Fig.  133,  3,  lower  section).  In  Lebrun's  corneal  operation 
an  almost  identical  section  is  made  upwards;  the  upper 
section  of  3,  Fig.  133,  if  placed  further  down  in  the  cornea, 
would  nearly  represent  it.  The  corneal  operations,  without 

FIG.  134. 


The  same  sections  seen  in  profile,  showing  the  plane  of  the  incision  in  1, 
2,  and  the  lower  section  of  3. 

iridectomy,  are  comparatively  easy  to  perform,  and  usually 
do  not  require  anaesthesia,  but  they  are  often  complicated 
by  extensive  adhesion  of  the  iris  to  the  scar.  It  is  un- 
likely that  they  will  gain  general  adoption. 

It  is  an  advantage  to  contract  the  pupil  with  eserine 
before,  and  to  continue  its  use  for  a  day  or  two  after,  the 
operations  c  and  d,  so  as  to  lessen  the  risk  of  the  iris  be- 
coming permanently  engaged  in  the  wound. 

(e)  Flap  extraction  (Daviel,  Beer). — The  incision  is 
slightly  within  the  visible  margin  of  the  cornea,  concentric 
with  it,  and  equal  to  at  least  half  its  circumference  (1, 
Fig.  133),  thus  forming  a  large  arc  of  a  small  circle ;  and 
the  plane  of  the  incision  is  parallel  with  that  of  the  iris 
(1,  Fig.  134).  No  iridectomy  is  made.  The  incision  is 
made  with  the  triangular  knife  of  Beer  (Fig.  135),  in 
which  the  blade  near  its  heel  is  somewhat  wider  than  the 
height  of  the  flap,  and  the  section  completed  by  simply 
pushing  the  knife  across  the  anterior  chamber  flat  with 


CATARACT.  367 

the  iris,  its  back  corresponding  to  the  base  of  the  intended 
flap.  The  inner  length  of  the  wound  is  less  than  the 
outer  by  the  thickness  of  the  obliquely  cut  cornea  at  each 
end  (1,  Fig.  133). 

The  after-treatment  in  flap  extraction  is  troublesome. 
When  everything  does  well  the  result  is  almost  perfect, 
the  pupil  retaining  its  natural  size,  shape,  and  mobility. 

FIG.  135. 


Beer's  cataract  knife. 

The  operation  is  usually  done  without  anaesthesia,  and 
neither  speculum  nor  fixation  forceps  are  needed.  The 
great  height  of  the  flap  in  proportion  to  its  width  renders 
it  very  liable  to  gape  or  even  to  fall  forwards,  and  this, 
with  the  fact  that  the  whole  wound  lies  in  corneal  tissue, 
considerably  increases  the  risk  of  rapid  suppurative  in- 
flammation of  the  cornea.  The  iris  often  prolapses  and 
becomes  adherent  to  the  wound,  and  even  apart  from  this, 
severe  iritis  is  a  common  occurrence.  For  these  reasons 
the  old  flap  extraction  has  been  almost  abandoned  in  favor 
of  the  peripheral  linear,  corneal  section,  and  short  flap 
operations,  which,  though  giving  perhaps  a  smaller  per- 
centage of  results  that  can  be  called  "  perfect,"  yield  a 
much  larger  average  of  useful  eyes. 

Historically,  the  flap  operation  was  the  earliest ;  then 
came  the  linear  operation  ;  thirdly,  the  modified  or  periph- 
eral linear  operation,  with  iridectomy;  and  lastly,  the 
modern  corneal  operations  and  short  flap,  the  aim  of  which 
is  to  gain  the  substantial  advantages  both  of  the  old  flap 
and  the  modified  linear  methods,  without  the  great  risks 
of  the  former  or  the  imperfections  of  the  latter. 

Of  other  operations  the  most  important  is  Pagenstecher's, 


368  OPERATIONS. 

in  which  the  lens  is  removed  by  means  of  a  scoop  or  vectis 
in  its  unbroken  capsule.  It  is  especially  applicable  to 
cataracts  which  are  over-ripe  or  are  complicated  with  old 
iritis,  and  to  Morgagnian  cataract. 

The  chief  complications  which  may  arise  during  extrac- 
tion of  cataract  are:  (1)  too  short  an  incision;  this  is  best 
remedied  by  enlarging  with  iris  scissors.  (2)  Escape  of 
vitreous  before  expulsion  of  the  lens ;  this  is  a  signal  for 
the  prompt  removal  of  the  lens  with  a  scoop  (Fig.  130), 
and  the  vitreous  is  to  be  cut  off  level  with  the  wound  by 
scissors.  (3)  Portions  of  the  lens  remaining  behind  after 
the  chief  bulk  has  been  expelled ;  they  should  be  coaxed 
out  by  gentle  manipulation  through  the  lower  lid  after 
removal  of  the  speculum. 

After-treatment  of  extraction  by  modified  linear,  short 
flap,  and  corneal  operations. — The  patient  is  best  in  bed 
for  a  week.  The  dressing  after  the  operation  consists  of 
a  piece  of  soft  linen  overlaid  by  a  pad  of  cotton-wool,  and 
kept  in  place  by  a  four-tailed  bandage  of  knitted  cotton, 
or  a  narrow  flannel  roller.  Both  eyes  are  to  be  bandaged. 
The  room  should  be  kept  nearly  dark  for  at  least  a  week, 
all  dressings  and  examinations  being  made  by  the  light  of 
a  candle.  The  dressings  are  removed  and  the  lids  gently 
cleansed  with  warm  water  twice  a  day,  their  edges  being 
just  separated  by  gently  drawing  down  the  lower  lid,  so  as 
to  allow  any  retained  tears  to  escape ;  this  cleansing  is  very 
grateful  to  the  patient.  Some  surgeons  open  the  lids  and 
look  at  the  eye  the  day  after  the  operation ;  others,  and 
amongst  them  myself,  prefer  to  leave  them  closed  for  several 
days  unless  there  are  signs  that  the  case  is  doing  badly 
(p.  184).1  It  is  a  good  practice  to  use  one  drop  of  atropine 

1  Old  people  occasionally  get  delirious  during  th«  confinement 
in  bed  after  iridectomy  or  extraction  of  cataract,  and  for  such 
patients  the  rules  as  to  bandaging  and  darkness  may  well  be  re- 
laxed. 


CATARACT.  369 

daily  after  the  third  day,  to  prevent  adhesions  should  iritis 
set  in.  During  the  first  few  hours  there  will  be  some  sore- 
ness and  smarting,  and  at  the  first  dressing  a  little  blood- 
stained fluid,  but  after  this  there  should  be  no  material 
discomfort,  and  nothing  more  than  a  little  mucous  dis- 
charge, such  as  old  people  often  have.  "When  first  exam- 
ined (from  two  to  seven  days  after  the  operation)  the  eye 
is  always  rather  congested  from  having  been  tied  up;  but 
there  should  be  no  chemosis,  the  wound  should  be  united  so  as 
to  retain  the  aqueous,  and  its  edges  clear.  The  pupil  is  ex- 
pected to  be  black,  unless  it  is  known  that  portions  of  lens- 
matter  have  been  left  behind.  If  all  be  well,  the  bandage 
may  be  left  off  during  the  daytime  at  the  end  of  a  week  or 
ten  days,  a  shade  being  worn;  but  the  bandage  should  be 
reapplied  at  night  for  the  first  two  or  three  weeks  to  pre- 
vent accidents  from  movements  during  sleep.  At  the  end 
of  a  fortnight,  if  the  weather  be  fine,  the  patient  may  begin 
to  go  out,  the  eyes  being  carefully  protected  from  light  and 
wind  by  dark  goggles,  and  he  may  be  out  of  the  surgeen's 
hands  in  from  three  to  four  weeks. 

AFTER-OPERATIONS. — When  iritis  occurs  (p.  185)  the 
pupil  becomes  more  or  less  occluded  by  false  membrane, 

FIG.  136. 


Diagram  of  occlusion  and  displacement  of  pupil  from  iritis  after 
upward  extraction  of  cataract. 

and  the  contraction  of  this  may  draw  the  iris  towards  the 
scar,  so  that  the  pupil  is  at  once  blocked  and  displaced 
(Fig.  136).  In  slight  cases  sight  is  greatly  improved  by 
simply  tearing  across  the  membrane  and  capsule  with  a  fine 


370  OPERATIONS. 

needle,  the  case  being  treated  for  a  few  days  as  after  needle 
operations  for  soft  cataract.  But  in  severer  cases  an  arti- 
ficial pupil  must  be  made,  either  by  iridectomy  or  iridotomy 
(p.  357). 

2.  Solution  or  discission  operations. — In  these  the  lens 
is  gradually  absorbed  by  the  action  of  aqueous  humor 
admitted  through  a  wound  in  the  capsule  (p.  180).  (1) 
The  pupil  is  fully  dilated  by  atropine;  (2)  an  anaesthetic 
is  given  unless  the  patient  is  old  enough  to  control  himself 
well,  for  the  slightest  movement  is  attended  by  risk;  (3) 
the  lids  are  held  open  by  the  fingers,  or  a  stop  speculum 
and  fixation  forceps  used ;  (4)  a  fine  cataract  needle  (Fig. 
137)  is  directed  to  a  point  a  little  within  the  border  of  the 

FIG.  137. 


Cataract  needle. 

cornea  (usually  the  outer  border),  and  when  close  to  its 
surface  is  plunged  quickly  and  rather  obliquely  into  the 
anterior  chamber.  Its  point  is  then  carried  to  the  centre 
of  the  pupil  (Fig.  138),  dipped  back  through  the  lens- 

FIG.  138. 


Discission  of  cataract. 

capsule,  and  a  few  gentle  movements  made  so  as  to  break 
up  the  centre  of  the  anterior  layers  of  the  lens ;  (6)  the 
needle  is  then  steadily  withdrawn.  Special  care  is  to  be 
taken  not  to  wound  nor  even  touch  the  iris,  either  on 
entering  or  withdrawing  the  needle,  and  not  to  stir  up  the 
lens  deeply  nor  too  freely. 


CATARACT.  371 

AFTER-TREATMENT. — The  pupil  to  be  kept  widely  di- 
lated with  atropine  (F.  24),  a  drop  being  applied  after  the 
operation,  and  at  least  six  times  a  day  afterwards,  or  much 
oftener  if  there  be  threatening  of  iritis.  Ice  or  iced  water 
is  in  every  case  to  be  applied  constantly  for  forty-eight 
hours  after  the  operation,1  as  for  traumatic  iritis  (p.  143), 
and  the  patient  to  remain  in  bed  in  a  darkened  room  for 
a  few  days.  A  little  ciliary  congestion  for  two  or  three 
days  need  cause  no  uneasiness,  but  the  occurrence  of  pain 
and  increase  of  congestion  with  alteration  in  the  color  of 
the  iris  (commencing  iritis),  are  indications  for  the  appli- 
cation of  leeches  near  the  eye,  and  the  more  frequent  use 
of  atropine. 

If  the  cataract  were  complete,  no  marked  change  will  be 
seen  for  some  weeks ;  if  partial  (e.  g.,  lamellar),  the  neigh- 
borhood of  the  needle  wound  will  become  opaque  in  one  or 
two  days.  In  from  six  to  eight  weeks  the  lens  will  have 
become  notably  smaller  (flattened  or  hollowed  on  the  front 
surface).  If  the  eye  be  perfectly  quiet,  but  not  unless,  the 
operation  may  now  be  repeated  in  exactly  the  same  way, 
and  with  the  same  after-treatment  and  precautions,  but  the 
needle  may  be  used  more  freely.  The  bulk  of  the  lens  will 
generally  disappear  after  the  second  operation,  but  the 
needle  often  needs  to  be  used  a  third  or  a  fourth  time  for 
the  disintegration  of  small  residual  pieces,  or  in  order  to 
tear  the  capsule  if  it  has  not  retracted  enough  to  leave  a 
clear  central  pupil.  A  small  whitish  dot  remains  in  the 
cornea  at  the  seat  of  each  needle  puncture. 

3.  Extraction  by  suction. — This  operation  is  applicable 
to  soft  cataracts.  The  eye  is  thoroughly  atropized,  and  an 
oblique  opening  made  in  the  cornea  with  a  keratome  or 
broad  needle  (Fig.  120)  between  its  centre  and  margin, 

1  I  have  to  thank  Mr.  Gunn,  the  late  able  house-surgeon  at 
Moorfields,  for  this  valuable  suggestion. 


372  OPERATIONS. 

and  the  lens-capsule  freely  lacerated.  The  needle  being 
withdrawn,  the  nose  of  the  syringe  is  passed  through  the 
wound  and  gently  dipped  into  the  lacerated  lens  substance. 
Very  gentle  suction  is  now  used,  and  the  semifluid  lens- 
matter  drawn  gradually  into  the  syringe.  The  instrument 
is  not  to  be  passed  behind  the  iris  in  search  of  fragments. 
Nearly  the  whole  of  the  lens  is  removed.  The  after-treat- 
ment is  the  same  as  for  needle  operations.  Two  forms  of 
syringe  are  in  use :  Teale's,  in  which  the  suction  is  made 
by  the  mouth  applied  to  a  piece  of  flexible  India-rubber 
tubing ;  Bowman's,  in  which  the  suction  is  obtained  by  a 
sliding  piston  worked  by  the  thumb  moving  along  the 
syringe.  It  is  often  better,  and  in  lamellar  cataract  neces- 
sary, to  break  up  the  lens  freely  with  a  fine  needle  a  few 
days  before  using  the  syringe,  and  thus  allow  it  to  be 
thoroughly  macerated  and  softened  in  the  aqueous  humor ; 
the  patient  must  be  kept  in  a  darkened  room,  and  atropine 
and  ice  used  freely  in  the  interval  between  the  needle 
operation  and  the  suction ;  and  the  surgeon  must  be  pre- 
pared to  interfere  before  the  day  appointed  for  the  suction 
should  inflammatory  symptoms  be  set  up  by  the  rapid 
swelling  of  the  lens. 

Suction  is  a  very  delicate  operation,  but  in  my  experi- 
ence highly  satisfactory.  If  the  lens  do  not  easily  enter 
the  syringe,  it  is  best  to  convert  the  operation  into  a  linear 
extraction  (p.  363,  a). 


PART  III. 


DISEASES  OF  THE  EYE  IN  RELATION  TO 
GENERAL  DISEASES. 


CHAPTE1I    XXIII. 

IN  stating  very  shortly  the  most  important  facts  bearing 
on  the  connection  between  diseases  of  the  eye  and  of  other 
parts  of  the  body,  it  is  convenient  to  make  the  following 
subdivisions :  (A)  the  eye-changes  occur  as  part  of  a  gen- 
eral disease;  (B)  the  ocular  disease  is  symptomatic  of 
some  local  malady  at  a  distance ;  (C)  the  eye  shares  in  a 
local  process,  affecting  the  neighboring  parts. 

(For  the  clinical  details  of  the  various  eye  diseases  re- 
ferred to  in  this  chapter,  see  Part  II. 

A.  General  diseases,  in  which  the  eye  is  liable  to  suffer. 

Syphilis  is,  directly  or  indirectly,  the  cause  of  a  large 
proportion  of  the  more  serious  diseases  of  the  eye. 

1.  Acquired  syphilis. — Primary  stage.  Hard  chancres 
are  occasionally  seen  on  the  eyelid.  I  have  once  seen  one 
far  back  on  the  conjunctiva. 

Secondary  stage  (sore  throat,  shedding  of  hair,  eruption, 
and  condylomata).  Iritis  is  common  between  two  and 
eight  or  nine  months,  and  does  not  occur  later  than  about 
eighteen  months,  after  the  contagion  ;  in  considerably  more 
than  half  the  cases  both  eyes  suffer ;  there  is  a  marked 
tendency  to  exudation  of  lymph  (plastic  iritis),  shown  by 

82  (  373  ) 


374  ETIOLOGY. 

keratitis  punctata,  haze  of  cornea,  and  less  commonly  by 
lymph-nodulea  on  the  iris.  In  some  cases  there  are  symp- 
toms of  severe  cyclitis  with  but  little  iritis ;  but  the  cyclitis 
of  acquired  syphilis  does  not  give  rise  to  ciliary  staphyloma 
(compare  p.  137).  Syphilitic  iritis,  though  sometimes  pro- 
tracted, rarely  relapses  after  complete  subsidence.  Cho- 
roiditis  and  retinitis  generally  set  in  rather  later,  from  six 
months  to  about  two  years  after  the  chancre.  The  two 
conditions  are  most  often  seen  together,  but  either  may 
occur  singly ;  and  in  each  the  vitreous  generally  becomes 
inflamed.  These  conditions  are  essentially  chronic,  the 
retinitis  being  often,  and  the  choroiditis  sometimes,  liable 
to  repeated  exacerbations  or  recurrences ;  whilst  in  some 
cases  the  secondary  atrophic  changes  progress  slowly  for 
years,  almost  to  blindness,  often  with  pigmentation  of  the 
retina.  Syphilitic  choroiditis  and  retinitis  usually  affect 
both  eyes,  but  often  in  an  unequal  degree.1  In  a  few  cases 
detachment  of  the  retina  and  secondary  cataract  occur  in 
secondary  syphilis.  Keratitis,  indistinguishable  from  that 
of  inherited  syphilis,  is  amongst  the  rarest  events  in  tha 
acquired  disease;  when  it  occurs  it  usually  does  so  in  the 
secondary  stage. 

Later  periods. — Ulceration  of  the  skin  and  conjunctiva 
of  the  lids,  gummatous  infiltration  of  the  lids,  and  nodes 
in  the  orbit  (whether  cellular  or  periosteal)  occur  but 
rarely.  Oculo-motor  paralysis  is  one  of  the  commonest 
ocular  results  of  syphilis.  It  may  depend  upon  gumma 
(syphilitic  neuroma)  of  the  affected  nerve  in  the  orbit  or 
in  the  skull,  or  upon  gummatous  inflammation  of  the  dura 
mater  at  the  base  of  the  skull,  matting  the  nerves  together, 

1  Choroiditis  sometimes  occurs  at  a  later  stage,  in  only  one  eye, 
and  without  retinitis,  when  it  deserves  to  be  classed  as  a  tertiary 
symptom.  But  these  cases  are,  I  believe,  much  less  common  than 
the  symmetrical  choroiditis  (or  choroido-retinitis)  of  secondary 
syphilis. 


ETIOLOGY.  375 

or  on  disease  of  nerve  centres,  causing  ophthalmoplegia 
externa.  The  gummatous  nerve  lesions  seldom  occur  very 
late  in  tertiary  syphilis. 

Diseases  of  the  optic  nerve  in  relation  to  acquired 
syphilis. — The  retinitis  of  the  secondary  stage  affects  the 
disk,  and  when  atrophy  of  the  retina  and  choroid  occur  the 
disk  becomes  wasted  in  proportion ;  in  rare  cases  the  reti- 
nitis of  secondary  syphilis  is  replaced  by  well-marked  pa- 
pillitis  of  local  origin.  Such  cases  must  not  be  confused 
with  others,  equally  rare,  in  which  double  papillitis,  passing 
into  atrophy,  occurs  with  all  the  symptoms  of  severe  men- 
ingitis in  secondary  syphilis.  Tertiary  syphilitic  disease, 
anywhere  within  the  cranium,  commonly  causes  papillitis, 
in  the  same  way  as  do  other  coarse  intracranial  lesions ; 
but  gummatous  inflammation  of  the  trunk  of  the  optic 
nerve,  or  of  the  chiasma,  may  also  be  the  cause  of  descend- 
ing neuritis.  Primary  progressive  atrophy  of  the  disks 
occurs  in  association  with  locomotor  ataxia  and  ophthalmo- 
plegia externa  of  syphilitic  origin ;  probably  in  a  few 
instances  the  optic  atrophy  occurs  alone,  or  for  a  time  pre- 
cedes the  other  changes,  in  syphilitic,  as  it  is  known  to  do 
in  non-syphilitic,  ataxia. 

2.  Inherited  syphilis. — In  the  secondary  stage.  Iritis 
corresponding  to  that  iu  the  acquired  disease  is  seen  in  a 
small  number  of  cases,  and  occurs  between  the  ages  of 
about  two  and  fifteen  months.  It  often  gives  rise  to  much 
exudation,  leading  to  occlusion  of  the  pupil,  and  is  fre- 
quently accompanied  by  deeper  changes.  It  is  very  often 
symmetrical,  and  is  much  commoner  in  girls  than  boys. 
Choroiditis  and  retinitis,  of  precisely  the  same  forms  as  in 
acquired  syphilis,  occur  at  the  corresponding  period  of  the 
disease,  i.  e.,  between  six  months  and  about  three  years  of 
age ;  and  they  show  as  much  (some  observers  think  more) 
tendency  to  the  degenerative  and  atrophic  results  already 
described.  In  the  later  stages  keratitis,  which  is  the  com- 


876  ETIOLOGY. 

monest  eye  disease  caused  by  inherited  syphilis,  occurs.  It 
'is  commonest  between  six  and  fifteen  years  old,  but  is 
sometimes  seen  as  early  as  two  or  three  years,  and  is  occa- 
sionally deferred  till  after  thirty.  The  disease  is  frequently 
complicated  with  iritis  and  cyclitis,  and,  though  tending 
to  recovery,  shows  a  considerable  liability  to  relapse.  It 
almost  always  attacks  both  eyes,  though  sometimes  at  an 
interval  of  many  months.  When  the  patient  is  unusually 
young,  the  disease  as  a  rule  runs  a  mild  and  short  course. 
The  oculo-motor  palsies  occur  but  rarely  in  inherited  syphi- 
lis, but  a  few  well-authenticated  cases  are  on  record. 

Smallpox  causes  inflammation  and  ulceration  of  the 
cornea,  leading,  in  the  worst  cases,  to  total  destruction,  but 
in  a  large  number  to  nothing  worse  than  a  chronic  vas- 
cular ulcer.  The  corneal  disease  comes  on  some  days  after 
the  eruption  (tenth  to  fourteenth  day  from  its  commence- 
ment), and  after  the  onset  of  the  secondary  fever.  Iritis, 
uncomplicated  and  showing  nothing  characteristic  of  its 
cause,  sometimes  occurs  some  weeks  after  an  attack  of 
smallpox.  Only  in  very  rare  cases  do  variolous  pustules 
form  on  the  eye,  and  even  then  they  are  always  on  the  con- 
junctiva, not  on  the  cornea. 

Scarlet  fever,  typhus,  and  some  other  exanthemata  may 
be  followed  by  rapid  and  complete  loss  of  sight,  lasting  a 
day  or  two,  showing  no  ophthalmoscopic  changes,  and  end- 
ing in  recovery.  Such  attacks  are  believed  to  be  ursemic, 
or  at  any  rate  dependent  on  some  toxic  condition  of  the 
blood.  A  peculiarity  of  these  cases  is  the  preservation  of 
the  action  of  the  pupils  to  light.  Very  severe  purulent  or 
diphtheritic  ophthalmia  sometimes  occurs  during  scarlet 
fever. 

Diphtheria. — By  far  the  commonest  result  is  paralysis 
(often  incomplete)  of  the  ciliary  muscles  (cycloplegia) ;  the 
pupils  are  not  affected  except  in  severe  cases,  when  they 


ETIOLOGY.  377 

may  be  rather  large  and  sluggish.1  The  symptoms  gener- 
ally come  on  from  four  to  six  weeks  after  the  commence- 
ment of  the  illness,  last  about  a  month,  and  disappear 
completely.  Diphtheritic  cycloplegia  is  usually,  but  not 
invariably,  accompanied  by  paralysis  of  the  soft  palate.  In 
most  of  the  cases  seen  by  ophthalmic  surgeons,  the  attack 
of  diphtheria  has  been  mild,  sometimes  extremely  so,  the 
case  often  being  described  as  "ulcerated  throat;"  but  in- 
quiry often  yields  a  history  of  other  and  severer  cases  in 
the  family,  and  of  general  depression  and  weakness  in  the 
patient,  out  of  proportion  to  his  throat  symptoms.  We  find 
that  most  of  the  patients  who  apply  with  diphtheritic  cyclo- 
plegia arc  hypermetropic,  doubtless  because  those  with 
normal  (and,  a  fortiori,  with  myopic)  refraction  are  much 
less  troubled  by  paresis  of  accommodation,  and  often  do 
not  find  it  necessary  to  seek  advice.  Concomitant  conver- 
gent squint  is  sometimes  developed  in  hypermetropic 
children  during  the  diphtheritic  paresis,  owing  to  the  in- 
creased efforts  at  accommodation  (p.  302).  Paralysis  of  the 
external  muscles  is  occasionally  seen ;  I  have  never  myself 
seen  any  except  the  external  rectus  affected,  and  recovery 
has  been  rapid. 

Diphtheritic  and  membranous  ophthalmia  are  occasion- 
ally caused  by  direct  inoculation  of  the  conjunctiva  by 
diphtheritic  material  from  the  throat  of  another  person; 
or  by  extension  up  the  nasal  duct  from  the  nose  to  the 
conjunctiva.  But  in  the  majority  of  cases  of  "  diphtheritic  " 
and  "  membranous  "  ophthalmia  the  disease  is  a  local  one, 
in  which  the  inflammation  takes  on  this  special  form ;  and 
they  occur  in  no  ascertainable  relation  to  any  infectious 
disease.  No  doubt  there  is  often  something  peculiar  in 
the  patient's  health,  or  in  the  state  of  his  eye-tissues,  which 
gives  a  proclivity  to  this  kind  of  inflammation.  Diph- 
theritic ophthalmia  of  all  degrees  is  more  common  in 

1  Further  observations  are  wanted. 
32* 


378  ETIOLOGY. 

young  children  than  in  adults.  The  worst  cases  generally 
occur  after  measles,  or  during  or  after  scarlet  fever, 
broncho-pneumonia,  or  severe  infantile  diarrhoea.  Old 
granular  disease  of  the  conjunctiva  also  confers  a  liability 
to  a  diphtheritic  type  of  inflammation,  and  the  same  ten- 
dency is  sometimes  seen  in  ophthalmia  neonatorum  and  in 
gonorrhoeal  ophthalmia.  As  there  seems  but  seldom  any 
reason  to  look  upon  diphtheritic  ophthalmia  as  the  local 
manifestation  of  a  specific  blood  disease,  the  term  "  diph- 
theria of  the  conjunctiva"  should,  I  think,  seldom  be  used. 

Measles  is  a  prolific  source  of  ophthalmia  tarsi  in  all  its 
forms,  and  of  corneal  ulcers,  particularly  of  the  phlycten- 
ular  forms.  It  also  gives  rise  to  a  troublesome  muco- 
purulent  ophthalmia,  and  under  bad  hygienic  conditions 
this  may  be  aggravated,  by  cultivation  and  transmission, 
into  destructive  disease  of  purulent,  membranous,  or  diph- 
theritic type. 

Chicken-pox  is  sometimes  followed  by  a  transient  attack 
of  mild  conjunctivitis. 

Whooping-cough  often,  like  measles,  leaves  a  proneness 
to  corneal  ulcers.  In  a  few  rare  cases  the  condition  known 
as  ischcemia  retina  (sudden  temporary  arterial  bloodless- 
ness)  has  occurred. 

Malarial  fevers,  especially  the  severe  forms  met  with  in 
hot  countries,  are  sometimes  the  cause  of  retinal  hemor- 
rhage (often  large  and  periarterial),  and  even  of  consid- 
erable neuro-retinitis ;  where  there  is  much  pigment  in  the 
blood,  the  swollen  disk  may  have  a  peculiar  gray  color. 
When  real  albuminuria  is  caused  by  malarial  disease, 
albuminuric  retinitis  may  occur. 

Relapsing  fever  is  sometimes  followed  during  conva- 
lescence by  inflammatory  symptoms  with  opacities  in  the 
vitreous  (cyclitis)  with  or  without  iritis;  recovery  takes 
place.  These  cases  are  commoner  in  some  epidemics  than 
in  others. 


ETIOLOGY.  379 

Epidemic  cerebro-spinal  meningitis  also,  in  a  few  cases, 
gives  rise  to  acute  choroiditis,  with  pain,  chemosis,  and 
great  tendency  to  rapid  exudation  of  lymph  into  the 
vitreous  and  anterior  chambers,  and  often  leading  to  dis- 
organization of  the  eye,  and  blindness.1  It  is  believed 
that  the  inflammation  may  either  extend  to  the  eye  along 
the  optic  nerve,  or  may  occur  independently  in  the  brain 
and  the  eye.  Deafness  from  disease  of  the  internal  ear  is 
even  commoner  than  the  eye  disease. 

Purpura  has  been  observed  in  a  few  cases  to  be  accom- 
panied by  retinal  or  subretinal  hemorrhages;  they  are 
sometimes  perivascular  and  linear,  and  in  other  cases  form 
large  blotches.  They  have  also  been  found  in  Scurvy. 

In  Pyaemia  one  or  both  eyes  may  be  lost  by  septic  emboli 
lodging  in  the  vessels  of  the  choroid  or  retina,  and  setting 
up  suppurative  panophthalmitis.  The  symptoms  are  swell- 
ing of  the  lids,  loss  of  sight,  congestion,  especially  of  the 
perforating  ciliary  vessels  (Fig.  22),  chemosis,  discoloration 
and  duluess  of  aqueous  and  iris.  There  may  or  may  not 
be  some  protrusion  and  loss  of  mobility,  and  conjunctival 
discharge.  Pain,  sometimes  very  severe,  may  be  almost 
absent;  probably  its  presence  indicates  rise  of  tension. 
A  yellow  reflex  is  often  seen  from  the  vitreous.  The  eye- 
ball generally  suppurates  if  the  patient  lives  long  enough. 
Sometimes  both  eyes  are  affected,  together  or  with  an  in- 
terval. In  cases  of  Septicaemia  abundant  retinal  hemor- 
rhages of  large  size  may  occur  in  both  eyes  ;  they  come  on 
a  few  days  before  death  and  are  thus  of  grave  significance. 
As  they  are  not  present  in  typhoid  and  other  fevers  of  cor- 
responding severity,  their  presence  is  sometimes  an  aid  in 
differential  diagnosis.1 

1  Possibly  some  of  the  cases  in  which  similar  eye  conditions  are 
seen  without  apparent  cause  may  be  the  accompaniments  of  slight 
and  unrecognized  meningitis.  (See  Pseudo-glioma,  p.  283.) 

3  Gowers,  Medical  Ophthalmoscopy,  2d  edit.,  p.  255. 


380  ETIOLOGY. 

Lead  poisoning  is  an  occasional  cause  of  optic  neuro- 
retinitis  leading  to  atrophy,  of  atrophy  ensuing  upon 
chronic  amblyopia,  and  of  rapid  and  usually  transient 
amblyopia.  The  former  two  are  the  most  common;  the 
atrophy,  whether  primary  or  consecutive  to  papillitis,  is 
generally  accompanied  by  very  marked  shrinking  of 
retinal  arteries,  and  great  defect  of  sight  or  complete 
blindness ;  it  is  generally  symmetrical,  but  one  eye  may 
precede  the  other.  Other  symptoms  of  lead  poisoning, 
usually  chronic  but  occasionally  acute,  are  nearly  always 
present.  Care  must  be  taken  not  to  confuse  albuminuric 
retinitis  from  kidney  disease  induced  by  lead,  with  the 
changes  here  alluded  to,  which  are  due  in  some  more  direct 
manner  to  the  influence  of  the  metal. 

The  deposition  of  lead  upon  corneal  ulcers  has  been  re- 
ferred to  at  p.  133. 

Alcohol. — Some  observers  still  hold  that  alcohol,  especi- 
ally in  the  form  of  distilled  spirits,  may  cause  a  particular 
form  of  symmetrical  amblyopia  (the  so-called  amblyopia 
potatorum).  The  difficulty  of  arriving  at  the  truth  de- 
pends chiefly  upon  the  fact  that  most  drinkers  are  also 
smokers,  and  that  tobacco,  whether  smoked  or  chewed,  is 
allowed  by  all  authorities  to  be  one  of  the  causes  (or  as 
most  now  hold,  the  sole  cause)  of  a  similar  disease.  The 
question  of  whether  alcohol  directly  causes  disease  of  the 
optic  nerves  will  not  be  settled  until  observers  are  much 
more  careful  than  they  have  hitherto  been  to  record  as 
typical  cases  of  alcoholic  amblyopia,  only  those  in  which 
the  patient  does  not  use  even  the  smallest  quantity  of 
tobacco  in  any  shape.  Magnan  thinks  alcoholic  amblyopia 
less  common  than  some  have  supposed.1 

Tobacco. — Whatever  may  be  the  truth  (and  it  is  con- 
fessedly difficult  to  arrive  at)  as  to  the  direct  influence  of 

1  Magnan  On  Alcoholism,  Greenfield's  translation,  p.  42. 


ETIOLOGY.  381 

alcohol,  and  of  the  various  substances  often  combined  with 
it,  there  is  no  doubt  whatever  that  tobacco,  whether  smoked 
or  chewed,  does  act  directly  on  the  optic  nerves,  and  in  such 
a  manner  as  to  give  rise  to  definite,  and  usually  very  char- 
acteristic, symptoms.  The  amblyopia  seldom  comes  on 
until  tobacco  has  been  used  for  many  years.  The  quantity 
needed  to  cause  symptoms  is,  cceteris  paribus,  a  matter  of 
idiosyncrasy,  and  very  small  doses  will  produce  the  disease 
in  men  who  in  other  respects  also  are  unable  to  tolerate 
large  quantities  of  the  drug.  Predisposing  causes  exert  a 
very  important  influence:  amongst  these  are  to  be  espe- 
cially noted  increasing  age ;  nervous  exhaustion  from 
overwork,  anxiety,  or  loss  of  sleep ;  chronic  dyspepsia, 
whether  from  drinking  or  other  causes ;  and  probably 
sexual  excesses,  and  exposure  to  tropical  heat  (or  light). 
A  large  proportion  of  the  patients  drink  to  excess,  and 
thus  make  themselves  more  susceptible  to  tobacco,  both  by 
injuring  the  nervous  system  and  the  stomach.  But  some 
remarkable  cases  are  seen  in  men  who  have  for  long  been 
total  abstainers,  in  others  who  have  lately  become  ab- 
stainers without  lessening  their  tobacco,  and  in  yet  others 
who  are  strictly  moderate  in  alcohol  and  in  whom  increas- 
ing age  is  the  only  recognizable  predisposing  cause.  The 
strong  tobaccos  produce  the  disease  far  more  readily  than 
the  weaker  sorts,  and  chewing  is  more  dangerous  than 
smoking.  Probably  alcohol  in  very  moderate  doses  coun- 
teracts, rather  than  increases,  the  injurious  effect  of  tobacco 
on  the  nervous  system  and  optic  nerves  (Hutchinson). 

Quinine,  taken  in  very  large  doses,  at  short  intervals, 
has  in  a  few  cases  caused  serious  visual  symptoms.  Sight 
in  both  eyes  may  be  totally  lost  for  a  time,  but  recovery, 
more  or  less  perfect,  takes  place  eventually,  sometimes  in  a 
few  days,  sometimes  not  for  months.  There  is  great  con- 
traction of  the  field  even  after  perfect  recovery  of  central 
vision ;  the  disks  are  pale  and  the  retinal  arteries  extremely 


382  ETIOLOGY. 

diminished.  The  symptoms  are  therefore  those  of  almost 
arrested  supply  of  arterial  blood  to  the  retina. 

Kidney  disease. — The  common  and  well-known  retino- 
neuritis,  associated  with  renal  albuminuria,  and  of  which 
several  clinical  types  are  found,  has  been  already  described. 
It  need  only  be  noted  that  the  disease  is  commonest  with 
chronic  granular  kidneys  and  in  the  kidney  disease  of 
pregnancy,  but  that  it  is  also  seen  in  the  chronic  forms  fol- 
lowing acute  nephritis  and  in  lardaceous  disease ;  and  that 
it  is  rare  in  children.  Detachment  of  the  retina  is  an  oc- 
casional result  in  extreme  cases.  The  prognosis  as  regards 
vision  is  best  in  the  cases  depending  on  albuminuria  of 
pregnancy.  The  retinitis  is  intimately  associated  with  the 
albuminuria,  though  the  nature  of  the  connection  is  obscure ; 
it  is  not  caused  by  the  cardiac  hypertrophy  which  is  so 
often  present.  The  failure  of  sight  caused  by  albuminuric 
retinitis  has  often  led  to  the  correct  diagnosis  of  cases  which 
had  been  treated  for  dyspepsia,  headache,  or  "  biliousness." 

Diabetes  sometimes  causes  cataract.  In  young  or  mid- 
dle-aged patients  the  cataract  usually  forms  quickly,  and 
is  of  course  soft.  As  it  is  always  symmetrical,  the  rapid 
formation  of  double  complete  cataract,  at  a  comparatively 
early  age,  should  always  lead  to  the  suspicion  of  diabetes. 
In  old  persons  the  progress  of  diabetic  cataract  is  much 
slower,  and  often  shows  no  peculiarities.  The  relation  of 
the  lenticular  opacity  to  the  diabetes  has  not  been  satis- 
factorily explained :  the  presence  of  sugar  in  the  lens,  the 
action  of  sugar  or  its  derivatives  dissolved  in  the  aqueous 
and  vitreous,  the  abstraction  of  water  from  the  lens  owing 
to  the  increased  density  of  the  blood,  and,  lastly,  degenera- 
tion of  the  lens  from  the  general  cachexia  attending  the 
disease,  have  all  been  offered  in  explanation.  In  a  few 
cases  retinitis  occurs  attended  by  great  osdema  and  copious 
(probably  capillary)  hemorrhages  into  the  retina  and 
vitreous.  In  other  cases  amblyopia  from  disease  of  the 


ETIOLOGY.  •  383 

optic  nerves  comes  on  and  may  closely  resemble  the  central 
amblyopia  caused  by  tobacco. 

Leucocythsemia  is  often  accompanied  by  retinal  hemor- 
rhages, less  commonly  by  whitish  spots  bordered  by  blood, 
and  consisting  of  white  corpuscles ;  these  spots  may  be  thick 
enough  to  project  forwards.  Occasionally  there  is  general 
haziness  of  the  retina.  In  severe  cases  the  whole  fundus  is 
remarkably  pale,  whether  there  be  other  changes  or  not.1 
The  changes  are  usually  symmetrical. 

Progressive  pernicious  anaemia  is  marked  by  a  strong 
tendency  to  retinal  hemorrhages ;  these  are  usually  grouped 
chiefly  near  the  disk,  and  are  striated  (Gowers).  White 
patches  are  also  common,  and  occasionally  well-marked 
neuritis  occurs.  I  have  seen  hemorrhages  of  different 
dates,  and  in  one  case,  shown  to  me  by  Dr.  Sharkey,  there 
had  evidently  been  a  large  extravasation  from  the  choroid 
at  an  earlier  period.  The  disk  and  fundus  participate  in 
the  general  pallor. 

Heart  disease  is  variously  related  to  changes  in  the  eyes 
and  alterations  of  sight.  Aortic  incompetence  often  pro- 
duces visible  pulsation  of  the  retinal  arteries.  This  pulsa- 
tion differs  from  that  seen  in  glaucoma  by  extending  in 
many  cases  far  beyond  the  disk,  and  in  not  being  so 
marked  as  to  cause  complete  emptying  of  the  larger  vessels 
during  the  diastole.  In  glaucoma  the  pulsation  is  confined 
to  the  disk.  The  difference  is  explained  by  the  different 
mode  of  production  in  the  two  cases ;  in  the  one  incomplete 
closure  of  the  aortic  orifice  lowers  the  pressure  in  the  whole 
blood-column  during  the  diastole,  and  allows  a  reflux  of 
blood  from  the  eye ;  in  the  other  heightened  intraocular 
tension,  telling  chiefly  on  the  comparatively  yielding 

1  For  a  full  account  of  the  changes,  see  Gowers'  Medical  Oph- 
thalmoscopy.  Dr.  Sharkey  has  lately  shown  me  a  case  with 
diffuse  retinitis,  very  numerous  punctiform  hemorrhages,  chiefly 
peripheral,  and  dilatation  with  extreme  tortuosity  of  the  veins. 


384  ETIOLOGY. 

tissues  of  the  optic  disk,  increases  the  resistance  to  the 
arterial  blood.  Valvular  disease  of  the  heart  is  generally 
present  in  the  cases  of  sudden  lasting  blindness  of  one  eye, 
clinically  diagnosed  as  embolism  of  the  arteria  centralis 
retina,  but  in  some  of  which  thrombosis  of  the  artery  or  of 
its  companion  vein,  or  blocking  of  the  internal  carotid1 
and  ophthalmic  arteries,  has  been  found  post-mortem.  Brief 
temporary  failure,  or  loss  of  sight,  is  not  uncommon  in  the 
subjects  of  valvular  heart  disease,  and  in  some  persons  who 
are  liable  to  recurring  headaches  (see  Megrim).  After  re- 
peated attacks  of  this  kind,  one  eye  sometimes  fails  to 
recover,  and  atrophy  of  the  disk  comes  on ;  possibly  re- 
peated temporary  failures  of  retinal  circulation  at  length 
give  rise  to  thrombosis.  In  another  group  of  cases  which 
needs  investigation,  sight  fails  during  successive  pregnan- 
cies or  lactations,  recovering  between  times ;  some  of  these 
may  be  cases  of  renal  retinitis ;  accommodative  asthenopia 
must  also  be  excluded  (p.  301).  It  is  probable  that  high 
arterial  tension  predisposes  to  intraocular  hemorrhage  in 
cases  where  the  small  vessels  are  unsound,  and  that  the 
frequent  association  of  retinal  hemorrhage  with  cardiac 
disease  is  thus  explained. 

Acute  generalized  tuberculosis  is  sometimes  accom- 
panied by  the  growth  of  miliary  tubercles  in  the  choroid ; 
they  are  most  common  when  there  is  no  meningitis.  Chronic 
large  growths  of  confluent  tubercles  are  occasionally  seen 
in  the  eye,  and  may  simulate  malignant  tumors.  There  is 
reason  to  suspect  that  choroidal  tubercles  sometimes  form 
in  cases  of  tubercular  meningitis  which  recover,  and  that 
certain  cases  of  localized  choroiditis  not  accompanied  by 
serious  general  symptoms  may  be  of  tubercular  character. 

Rheumatism. — In  acute  rheumatism  Dr.  Barlow  informs 
me  that  he  has  more  than  once  seen  well-marked  conges- 

1  Gowers'  Medical  Ophthalmoscopy,  p.  29. 


ETIOLOGY.  385 

tion  of  the  eyes  and  photophobia ;  but  neither  iritis  nor 
other  inflammatory  changes  occur.  The  subjects  of  chronic 
rheumatism  are,  however,  subject  to  relapsing  iritis.  Some 
of  these  patients  give  a  history  of  acute  articular  rheuma- 
tism as  the  starting-point  of  their  chronic  troubles,  others 
of  a  prolonged  subacute  attack,  lasting  for  many  months, 
whilst  in  others  again  the  articular  symptoms  have  never 
been  severe.  In  yet  another  series  a  liability  to  facial  or 
muscular  rheumatism,  or  to  recurrent  neuralgia  from  ex- 
posure to  cold  or  damp,  is  the  only  "rheumatic"  symp- 
tom of  which  a  history  is  given ;  in  some  of  these  the 
neuralgia  is  probably  gouty.  It  is  to  be  remembered  that 
the  eye  is  now  and  then  the  first  part  to  be  attacked  by 
an  inflammation,  which  later  events  show  to  be  clearly  re- 
lated to  rheumatism  or  to  gout. 

Gonorrhoaal  rheumatism  is  not  unfrequently  the  starting- 
point  of  relapsing  iritis  and  chronic  relapsing  rheumatism. 
Rheumatic  iritis  occurring  for  the  first  time  in  the  primary 
attack  of  gonorrhceal  rheumatism  is,  in  my  experience, 
more  often  symmetrical  than  other  forms  of  arthritic  iritis, 
or  than  the  later  attacks  of  iritis  in  the  same  patient ;  a 
fact  which  sometimes  makes  the  distinction  between  rheu- 
matic and  syphilitic  iritis  difficult. 

It  is  believed  that  rheumatism  is  the  cause  of  some  cases 
of  non-suppurating  orbital  cellulitis,  and  of  relapsing  epi- 
scleritis.  Rheumatism  is  also  believed  to  cause  some  of  the 
ocular  paralyses. 

Gout. — Gouty  persons  are  not  very  unfrequently  the  sub- 
jects of  recurrent  iritis  indistinguishable  from  that  which 
occurs  in  rheumatism.  Rheumatism  and  gout  seem  some- 
times so  mixed  that  it  is  not  always  possible  to  assign  to 
each  its  right  share  in  the  causation  of  iritis ;  but  that  the 
subjects  of  true  "  chalk  gout "  are  liable  to  relapsing  iritis 
is  undoubted.  There  is,  on  the  whole,  more  tendency  to 
insidious  forms  of  iritis  in  gout  than  in  rheumatism.  It  is 

33 


386  ETIOLOGY. 

also  generally  believed  that  the  subjects  of  gout,  or  persons 
whose  near  relatives  suffer  from  it,  are  particularly  subject 
to  glaucoma;  acute  glaucoma  was  indeed  the  "arthritic 
ophthalmia"  of  earlier  authors.  Hemorrhagic  retinitis  is 
also  commoner  in  gouty  persons  than  in  others ;  it  may  be 
single  or  double,  and  is  to  be  distinguished  from  albu- 
min uric  retinitis.  It  has  also  been  observed  that  the 
children  or  descendants  of  gouty  persons,  without  being 
themselves  subject  to  gout,  are  sometimes  attacked  in  early 
adult  life  by  an  insidious  form  of  irido-cyclitis  often  leading 
to  secondary  glaucoma  and  serious  damage  to  sight  j1  both 
eyes  are  attacked  sooner  or  later.  The  cases  in  this  group 
probably  seem  rarer  than  they  are,  from  the  impossibility 
in  many  instances  of  getting  a  full  family  history. 

Several  different  clinical  types  may  be  recognized  in  the 
large  group  of  maladies  referred  to  in  this  section  under 
the  name  of  "iritis."  Besides  cases  of  pure  iritis,  we  may 
distinguish  some  as  cyclitis,  in  some  cases  with  increase,  in 
others  with  decrease  of  tension ;  in  another  group  the 
sclerotic  and  conjunctiva  are  chiefly  affected  (true  "rheu- 
matic ophthalmia"  without  iritis);  a  fourth  group,  in 
which  the  pain  is  disproportionately  severe,  may  be  spoken 
of  as  neuralgic.  In  a  large  majority,  however,  the  iris  is 
the  headquarters  of  the  morbid  action.  All  arthritic  eye 
diseases  are  marked  by  a  strong  tendency  to  relapse ;  they 
usually  attack  only  one  eye  at  a  time,  though  both  suffer 
sooner  or  later ;  and  they  are  all  much  influenced  by  con- 
ditions of  weather,  being  commonest  in  spring  and  autumn. 

The  strumous  condition  is  a  fruitful  source  of  superficial 
eye  diseases,  which  are  for  the  most  part  tedious  and  re- 
lapsing, are  often  accompanied  by  severe  irritative  symp- 
toms, but,  as  a  rule,  do  not  lead  to  serious  damage.  The 
best  types  are — (1)  the  different  varieties  of  ophthalmia 

1  Hutchinson,  Lancet,  Jan.  1873. 


ETIOLOGY.  387 

tarsi ;  (2)  all  forms  of  phlyctenular  ophthalmia  ("  pus- 
tular" or  "herpetic"  diseases  of  the  cornea  and  con- 
junctiva) ;  (3)  many  superficial  relapsing  ulcers  of  cornea 
in  children  and  adolescents,  though  not  distinctly  phlyc- 
tenular in  origin,  are  certainly  strumous ;  (4)  many  of  the 
less  common,  but  very  serious  varieties  of  cyclo-keratitis  in 
adults  occur  in  connection  with  lowered  health,  suscepti- 
bility to  cold,  and  sluggish  but  irritable  circulation,  if  not 
with  decidedly  scrofulous  manifestations ;  (5)  lupus  is,  of 
course,  a  strumous  disease,  whether  attacking  the  parts 
around  the  eye  or  other  parts. 

Entozoa  sometimes  come  to  rest  and  develop  in  the  eye 
or  orbit.  The  commonest  intraocular  parasite  is  the  cysti- 
cercus  celluloses;  it  is  excessively  rare  in  this  country,  but 
commoner  on  the  Continent.  The  cysticercus  may  be  found 
either  beneath  the  retina,  in  the  vitreous,  or  upon  the  iris, 
and  may  sometimes  be  recognized  in  each  of  these  positions 
by  its  movements.  The  parasite  has  been  successfully  ex- 
tracted from  the  vitreous ;  when  situated  on  the  iris  its 
removal  involves  an  iridectomy.  Sometimes  it  develops 
under  the  conjunctiva,  where  I  have  seen  it  set  up  sup- 
purative  inflammation.  The  echinoeoccus  hydatid  with 
multiple  cysts  may  develop  to  a  large  size  in  the  orbit,  and 
cause  much  displacement  of  the  eyeball. 

B.  Eye  disease,  or  eye  symptoms,  indicative  of  local  dis- 
ease at  a  distance. 

Megrim  is  well  known  to  be  sometimes  accompanied  or 
even  solely  manifested  by  temporary  disorder  of  sight. 
This  generally  takes  the  form  of  a  flickering  cloud  ("  flit- 
tering scotoma  "  of  German  authors)  with  serrated  borders, 
which,  beginning  near  the  centre  of  the  field,  spreads 
eccentrically  so  as  to  produce  a  large  defect  in  the  field,  a 
sort  of  hemianopsia;  the  borders  of  the  cloud  may  be 
brilliantly  colored.  It  affects  both  eyes,  and  is  visible 
when  the  lids  are  closed.  The  attack  lasts  only  a  short 


388  ETIOLOGY. 

time,  and  perfect  sight  returns.  In  many  patients  this 
amblyopia  is  the  precursor  of  a  severe  sick  headache,  but 
in  others  it  constitutes  the  whole  attack ;  it  never  follows 
the  headache.  Less  definite  and  characteristic  symptoms 
(dimness,  cloudiness,  or  nauscsc)  are  complained  of  by  some 
patients. 

Neuralgia  of  the  fifth  nerve,  especially  of  its  first  divi- 
sion, in  a  few  cases  precedes  or  accompanies  failure  of  sight 
in  the  corresponding  eye  with  neuritis  or  atrophy  of  the 
disk  (p.  240,  3).  A  liability  to  neuralgia  of  the  face  and 
head  is  not  unfrequently  observed  in  persons  who  subse- 
quently suffer  from  glaucoma.  Intense  neuralgic  pain  in 
the  face  or  head  sometimes  causes  dimness  of  sight  of  the 
same  eye,  whilst  the  pain  lasts.  The  old  belief  that  injury 
to  branches  of  the  fifth  nerve  can  cause  amaurosis  is  not 
borne  out  by  modern  experience,  injury  to  the  optic  nerve 
by  fracture  of  the  skull  furnishing  the  true  explanation  of 
such  cases  (p.  237). 

Sympathetic  ophthalmitis  is  the  only  known  instance  in 
which  inflammation  of  the  eyeball  is  caused  by  local  dis- 
ease of  an  independent  part. 

Diseases  of  the  central  nervous  system  may  be  shown 
in  the  eye  either  at  the  optic  disk  (papillitis  and  atrophy), 
or  in  the  muscles  (strabismus  and  diplopia). 

The  diseases  which  most  often  cause  papillitis  are  intra- 
cranial  tumors,  syphilitic  growths,  and  meningitis.  Abscess 
of  the  brain  and  softening  from  embolism  and  thrombosis 
less  commonly  cause  it,  and  cerebral  hemorrhage  scarcely 
ever.  Papillitis  has  been  found  in  a  few  cases  of  acute  and 
subacute  myelitis;1  it  does  not  occur  in  spinal  meningitis. 

In  a  very  large  proportion  (Dr.  Gowers  thinks  at  least 
four-fifths)  of  all  the  cases  of  cerebral  tumor  (including 
syphilitic  growths)  neuritis  occurs  at  some  period.  The 

1  Gowers,  loc.  cit,  p.  161 ;  Dreschfeld,  Lancet,  Jan.  7,  1882. 


ETIOLOGY.  389 

severity  and  duration  of  the  neuritis  vary  much,  and  prob- 
ably depend  in  many  cases  on  the  rate  of  progress,  as  well 
as  on  the  character,  of  the  morbid  growth.  It  not  uncom- 
monly sets  in  at  no  long  interval  before  death,  whilst  in 
other  cases  it  is  very  chronic.  There  is  nothing  in  the 
characters  or  course  of  the  neuritis  to  help  us  in  the  locali- 
zation of  intracranial  tumor;  and  except  that  a  very  high 
degree  of  neuritis,  with  signs  of  great  obstruction  to  the 
retinal  circulation,  generally  indicates  cerebral  tumor,  the 
pathological  character  of  the  intracranial  disease,  whether 
tumor,  meningitis,  or  syphilitic  disease,  is  not  much  eluci- 
dated by  the  mere  occurrence  of  papillitis.  Tumors  also 
sometimes  cause  simple  optic  atrophy  by  pressing  upon  or 
invading  some  part  of  the  optic  fibres. 

Intracranial  syphilitic  disease  is  a  common  cause  of 
papillitis,  the  disease  being  either  a  gummatous  growth  in 
the  brain,  or  a  growth  or  thickening  beginning  in  the  dura 
mater,  or  basilar  meningitis.  The  prognosis  is  much  better 
than  in  cerebral  tumors  if  vigorous  treatment  be  adopted 
early,  and  in  all  cases  of  papillitis,  where  intracranial  dis- 
ease is  diagnosed  and  syphilis  even  remotely  possible, 
mercury  and  iodide  of  potassium  should  be  promptly 
given. 

Meningitis  often  causes  papillitis,  but  in  this  respect 
much  depends  on  its  position  and  duration.  Meningitis 
limited  to  the  convexity,  whatever  its  cause,  is  seldom  ac- 
companied by  ophthalmoscopic  changes;  on  the  other 
hand,  basilar  meningitis  very  often  causes  neuritis.  The 
neuritis  in  basilar  meningitis  is  probably  proportionate  to 
the  duration  and  intensity  of  the  intracranial  mischief, 
being  comparatively  slight  in  acute  and  rapidly  fatal  cases, 
whether  tubercular  or  not.  In  tubercular  cases  the  disease 
se^ms  especially  related  to  the  occurrence  of  inflammatory 
changes  about  the  chiasma  (Gowers) ;  and  the  neuritis  in 
cases  of  cerebral  tumor  also  seems  sometimes  to  be  caused 

33* 


390  ETIOLOGY. 

by  secondary  meningitis  set  up  by  the  growth.  When 
patients  recover  from  meningitis  the  neuritis  may  pass  into 
atrophy  and  cause  amaurosis;  such  cases  are  commonest 
in  children,  and  form  a  group,  well  known  to  ophthalmic 
surgeons;  it  is  probable  that  some  of  them  may  be  in- 
stances of  recovery  from  tubercular  meningitis.  In  rare 
cases  papillitis  occurs  with  severe  head  symptoms,  ending 
in  death,  but  without  microscopic  changes  in  the  brain  or 
membranes.  Microscopical  changes  in  the  brain  substance, 
justifying  the  term  cerebritis,  have  been  found  in  one  such 
case  by  Dr.  Button,  and  in  another  by  Dr.  Stephen  Mac- 
kenzie. It  must  not  be  forgotten  that  optic  neuritis  may 
be  caused  by  various  altered  conditions  of  the  blood ;  and 
that  it  is  occasionally  seen  without  any  evidence  either  of 
central  nervous  disease  or  of  a  morbid  state  of  the  blood. 
Cerebral  tumors  also  sometimes  cause  atrophy  from  press- 
ure, without  papillitis. 

Hydrocephalus  rarely  causes  papillitis,  but  often  at  a 
late  stage  causes  atrophy  of  the  optic  nerves  from  the 
pressure  of  the  distended  third  ventricle  on  the  chiasma. 
Dr.  Barlow  informs  me  that  he  has  several  times  seen  a 
very  gross  form  of  choroiditis  ending  in  immense  patches 
of  atrophy;  I  have  recorded  one  such  case  and  seen 
others. 

The  diseases  most  commonly  causing  atrophy  not  pre- 
ceded by  papillitis  are  the  chronic  progressive  diseases  of 
the  spinal  cord,  especially  locomotor  ataxia.  The  atrophy 
in  these  cases  is  slowly  progressive,  double,  though  seldom 
beginning  at  the  same  time  in  both  eyes,  and  it  always 
ends  in  blindness,  although  sometimes  not  until  after  many 
years.  Similar  atrophy  sometimes  occurs  in  the  early 
stages  of  general  paralysis  of  the  insane,  but  chiefly  in 
cases  complicated  by  marked  ataxic  symptoms.  It  is  also, 
but  much  more  rarely,  seen  in  lateral  and  in  insular 
sclerosis.  In  the  latter,  amblyopia  without  ophthalmo- 


ETIOLOGY.  891 

scopic  changes  is  occasionally  seen,  and  sight  may  improve 
or  almost  recover  after  having  been  defective  for  some 
time. 

Motor  disorders  of  the  eyes. — Some  of  the  commoner 
causes  of  ocular  palsy  have  been  already  given.  It  may 
be  mentioned  here  that  basilar  meningitis  often  causes 
paralysis  of  one  or  more  of  the  ocular  nerves  with  squint- 
ing (and  double  vision  if  the  patient  be  conscious),  and 
further,  that  the  palsy  in  such  cases  often  varies,  or  appears 
to  vary,  from  day  to  day. 

Locomotor  ataxia  and  general  paralysis  of  the  insane  are 
sometimes  preceded  by  paralysis  (usually  temporary)  of 
one  or  more  of  the  eye  muscles,  causing  diplopia ;  and  there 
may  for  years  be  nothing  else  to  attract  attention.  The 
same  diseases  may  also  be  ushered  in  by  internal  ocular 
paralysis.  The  most  frequent  variety  is  loss  of  the  reflex 
action  of  the  pupils  whilst  their  associated  action  remains ; 
when  shaded  and  lighted  they  remain  absolutely  motion- 
less, but  they  dilate  when  accommodation  is  relaxed  and 
contract  when  it  is  in  action  (p.  39).  This  phenomenon  is 
known  as  the  "Argyll  Robertson  symptom."1  It  is  often, 
though  by  no  means  always,  associated  with  a  permanently 
contracted  state  of  the  pupils,  and  hence  the  term  "spinal 
myosis"  is  often,  but  incorrectly,  used.  This  reflex  pa- 
ralysis of  the  iris  is  one  of  the  most  valuable  of  the  early 
signs  of  locomotor  ataxia.  We  do  not,  however,  yet  know 
how  often  it  may  occur  in  healthy  persons  or  without 
eventual  spinal  disease;  it  certainly  has  comparatively 
little  significance  in  old  persons.  The  complementary 
symptom,  loss  of  associated,  with  retained  reflex,  action  of 
the  pupils  has  not  been  fully  studied.  Any  of  the  other 
internal  paralyses  may  also  in  certain  cases  occur  as  a  pre- 
cursor of  ataxia.  Paralysis  of  one  third  nerve  coming  on 

1  Argyll  Robertson,  Edinburgh  Med.  Journ.,  1869,  703. 


ETIOLOGY. 


with  hemiplegia  of  the  opposite  side  may,  but  does  not 
necessarily,  indicate  disease  of  the  cms  cerebri  on  the  side 
of  the  palsied  third  nerve.1  Ophthalmoplegia  externa  has 
been  already  mentioned ;  it  may  here  be  added  that  cases 
occur  in  which  this  condition  appears  to  be  "  functional," 
in  which  at  any  rate  the  symptoms  come  on  quickly  and 
pass  off  completely,  coming  on  again  perhaps  at  a  later 
period ;  of  these  cases,  I  have  seen  several  in  young  adults. 

Ophthalmoplegia  externa  is  the  extreme  type  of  a  large 
and  important  class  of  ocular  palsies,  to  which  much  atten- 
tion has  been  given  recently,  characterized  by  the  paralysis 
of  certain  movements  (usually  associated  movements  of  the 
two  eyes),  not  of  the  muscles  supplied  by  a  certain  nerve. 
There  may,  e.  g.,  be  loss  of  power  of  both  eyes  to  look  up- 
wards (both  superior  recti)  or  loss  of  power  to  look  to  the 
right  (R.  external  and  L.  internal  rectus)  ;  and  yet  in  the 
latter  case  the  L.  internal  rectus  if  differently  associated, 
as  with  the  R.  internal  during  convergence,  may  act  per- 
fectly well.  Such  associated  paralyses  are  explained  by 
lesions  affecting  the  centres  for  certain  combined  move- 
ments, which  are  more  'central  anatomically  and  higher 
physiologically,  than  the  centres  of  origin  of  the  nerve- 
trunks.  The  symptoms  may  be  temporary  or  permanent, 
acute  or  chronic,  and  caused  by  various  fine  or  coarse 
anatomical  changes;  and  they  are  frequently  associated 
with  other  and  graver  nervous  symptoms.  From  the 
ophthalmic  point  of  view,  it  is  of  great  importance  to  make 
the  differential  diagnosis  between  cases  of  peripheral  palsy 
due  to  disease  of  the  trunks  of  the  third  or  other  ocular 
nerves,  and  cases  of  associated  palsy  which  should  usually 
be  relegated  to  the  physician. 

Insular  (disseminated)  sclerosis  is  often  accompanied  by 

1  For  exceptions,  see  Robin,  Troubles  Oculaires  dans  lea  Mai.  de 
l'Ence"phale,  1880,  p.  95. 


ETIOLOGY.  393 

nystagmus,  characterized  by  irregularity,  both  of  the  am- 
plitude and  rapidity  of  the  movements. 

There  appears  to  be  an  intimate  relation  between  the 
occurrence  of  Convulsions  and  the  formation  of  lamellar 
cataract,  this  form  of  cataract  being  scarcely  ever  seen 
except  in  those  who  have  had  fits  in  infancy.  A  very 
striking  deformity  of  the  teeth  is  also  nearly  always  present, 
depending  upon  an  abruptly  limited  deficiency  or  absence 
of  the  enamel  on  the  part  furthest  from  the  gum.  The 
teeth  affected  are  the  first  molars,  incisors,  and  canines,  of 
the  permanent  set.  The  dental  changes  are  quite  different 
from  those  which  are  pathognomonic  of  inherited  syphilis, 
although  mixed  forms  are  sometimes  seen.  The  relation 
between  the  convulsions,  the  cataract,  and  the  defective 
dental  enamel  has  not  been  satisfactorily  explained.  Mr. 
Hutchinson  has  collected  many  facts  in  favor  of  the  belief 
that  the  dental  defect  is  due  to  stomatitis  interfering  with 
the  calcification  of  the  enamel  before  the  eruption  of  the 
teeth,  and  that  mercury  is  the  commonest  cause  of  this 
stomatitis.  On  this  hypothesis  the  coincidence  of  the  dental 
defect  and  the  cataract  is  due  to  mercury  having  been 
usually  prescribed  for  the  infantile  convulsions  from  which 
these  cataractous  children  suffer.  There  also  seems,  how- 
ever, much  probability  in  the  supposition  that  the  defect 
of  the  crystalline  lens  and  of  the  enamel,  both  of  them  epi- 
thelial structures,  may  be  caused  by  some  common  in- 
fluence ;  although  the  facts  that  the  peculiar  teeth  are 
often  seen  without  the  cataract,  and  the  cataract  occa- 
sionally seen  with  perfect  teeth,  appear  to  weaken  this 
view. 

C.  Cases  in  which  the  eye  shares  in  a  local  process  affect- 
ing the  neighboring  parts. 

In  herpes  zoster  of  the  first  division  of  the  fifth  nerve 
the  eye  participates.  When  only  the  supra-orbital  or 
supra-trochlear  branches  are  attacked,  the  eyeball  usually 


394  ETIOLOGY. 

escapes,  or  is  only  superficially  congested.  But  if  the 
eruption  occur  on  the  parts  supplied  by  the  nasal  branch 
(i.  e.,  if  the  spots  extend  down  to  the  tip  of  the  nose),  there 
is  usually  inflammation  of  the  proper  tissues  of  the  eyeball 
(ulceration  or  infiltration  of  cornea,  and  iritis) ;  for  the 
sensitive  nerves  of  the  cornea,  iris,  and  choroid  are  derived, 
through  the  long  root  of  the  ophthalmic  ganglion,  from  the 
nasal  branch.  Occasionally  the  eye  suffers,  however,  when 
the  nasal  branch  escapes.  The  pain  and  swelling  of  the 
herpetic  region  are  often  so  great  that  the  attack  gets  the 
name  of  "erysipelas."  In  rare  cases  paralysis  of  the  third 
and  atrophy  of  the  optic  nerve  occur  with  the  herpes. 

In  paralysis  of  the  first  division  of  the  fifth  the  cornea 
and  conjunctiva  are  anaesthetic ;  the  cornea  may  be  touched 
or  rubbed  without  the  patient  feeling  it  at  all.  In  many 
cases  ulceration  of  the  cornea,  usually  uncontrollable  and 
destructive  in  character,  takes  place.  It  is  doubtful 
whether  this  is  due  directly  to  paralysis  of  trophic  fibres 
running  in  the  trunk  of  the  fifth,  or  indirectly  to  the  an- 
aesthesia. The  ansesthesia  operates  first  by  allowing  injuries 
and  irritations  to  occur  unperceived,  and,  secondly,  by  re- 
moving the  reflex  effect  of  the  sensitive  nerves  on  the 
calibre  of  the  bloodvessels,  and  thus  permitting  inflamma- 
tion to  go  on  uncontrolled. 

In  paralysis  of  the  facial  nerve  the  eyelids  cannot  be 
shut,  and  the  cornea  remains  more  or  less  exposed.  When 
a  strong  effort  is  made  to  close  the  lids  the  eyeball  rolls  up- 
wards beneath  the  upper  lid.  Epiphora  is  a  common  result 
of  facial  palsy.  Severe  ulceration  of  the  cornea  may  result 
from  the  exposure. 

Paralysis  of  the  cervical  sympathetic  causes  some  nar- 
rowing of  the  palpebral  fissure  from  slight  drooping  of  the 
upper  lid,  apparent  recession  of  the  eye  into  the  orbit,  and 
more  or  less  myosis  from  paralysis  of  the  dilator  of  the 
pupil  (p.  329).  No  changes  are  observed  in  the  calibre  of 


ETIOLOGY.  395 

the  bloodvessels  of  the  eye.  The  pupil  is  said  to  be  less 
contracted  after  division  of  the  sympathetic  trunk  than 
when  the  trunk  of  the  fifth  (and  Avith  it  the  oculo-sympa- 
thetic  fibres)  is  cut,  and  knowledge  of  this  may  be  now  and 
then  useful  in  diagnosis. 

In  exophthalmic  goitre  the  eyeballs  are  too  prominent, 
and  the  protrusion,  though  not  always  quite  equal,  is 
almost  invariably  bilateral.  It  is  often  apparently  in- 
creased in  slight  cases  by  an  involuntary  and  excessive 
retraction  of  the  upper  lids,  especially  when  the  patient 
looks  down.  In  severe  cases  the  proptosis  may  be  so  great 
as  to  prevent  full  closure  of  the  lids,  and  in  these  ulceration 
of  the  cornea,  is  to  be  feared.  In  such  cases  it  is  beneficial 
to  shorten  the  palpebral  fissure  by  uniting  the  borders  of 
the  lids  at  the  outer  canthus,  or  even  to  unite  the  lids  in 
their  whole  length  (p.  338).  No  changes  are  present  in 
the  fundus,  excepting  sometimes  dilatation  of  arteries  and 
spontaneous  arterial  pulsation. 

Erysipelas  of  the  face  sometimes  invades  the  deep  tissues 
of  the  orbit  and  causes  blindness  by  affecting  the  optic 
nerve  and  retina.  On  recovering  from  the  erysipelas  in 
such  a  case  the  eye  is  found  to  be  blind  and  the  ophthalmo- 
scope shows  either  simple  atrophy  of  the  disk,  or  signs  of 
past  retinitis  also.  Other  forms  of  orbital  cellulitis  may 
lead  to  the  same  result. 

Note  on  the  teeth  in  hereditary  syphilis. — None  of  the 
first  set  of  teeth  are  characteristically  altered,  though  the 
incisors  frequently  decay  early. 

In  the  permanent  set  only  two  teeth,  the  central  upper 
incisors,  are  to  be  relied  upon;  but  the  other  incisors,  both 
upper  and  lower,  and  the  first  molars,  are  often  deformed 
from  the  same  cause.  The  characteristic  change  in  the 
upper  central  incisors  appears  to  depend  upon  defective 
formation  of  the  dentine,  and  in  a  less  degree  of  the 
enamel,  of  the  central  lobe  of  the  tooth.  Soon  after  the 


396  ETIOLOGY. 

eruption  of  the  tooth  this  lobe  wears  away,  leaving  at  the 
centre  of  the  cutting  edge  a  vertical  notch.  If  the  cause 
have  acted  so  intensely  as  entirely  to  prevent  the  develop- 
ment of  the  central  lobe,  we  find,  instead  of  the  notch,  a 
narrowing  and  thinning  of  the  cutting  edge  in  comparison 
with  the  crown,  and  this,  according  to  its  degree,  produces 
a  resemblance  to  a  screw-driver,  or  to  a  peg.  The  teeth 
are  also  usually  too  small  in  every  dimension,  so  that  the 
incisors  are  often  separated  from  one  another  by  consider- 
able spaces.  In  extreme  cases  all  the  incisors  are  peggy 
and  much  dwarfed. 


APPENDIX 


FORMULAE,  ETC. 

NITRATE  OF  SILVER  : 

1.  Mitigated  Solid  Nitrate  of  Silver  : 

Nitrate  of  Silver  2, 
Nitrate  of  Potash  1. 

Fused  together  and  run  into  moulds  to  form  short,  pointed 
sticks. 

Used  for  granular  lids  and  purulent  ophthalmia. 

The  strength  above  given  is  known  as  No.  1,  and  is  that  which 
I  generally  use;  three  weaker  forms  are  made,  known  as  Nos.  2, 
3,  and  4,  containing  respectively  3,  3£,  and  4  parts  of  nitrate  of 
potash  to  1  of  nitrate  of  silver. 

Pure  nitrate  of  silver  is  never  to  be  used  to  the  conjunctiva. 

2.  Solutions  of  Nitrate  of  Silver  : 

(1)  Nitrate  of  Silver  gr.  x  or  xx, 

Distilled  Water  §j. 

Used  by  the  surgeon  for  purulent  ophthalmia,  recent  granular 
lids,  and  some  cases  of  ulcer  of  the  cornea. 

3.  (2)  Nitrate  of  Silver  gr.  j  or  ij, 

Distilled  Water  |j. 

Used  by  the  patient  in  various  forms  of  acute  ophthalmia; 
only  a  few  drops  to  be  used  at  a  time,  and  not  more  than  three 
times  a  day. 

All  solutions  of  nitrate  of  silver  should  be  kept  either  in  a 
deep-blue  bottle,  or  in  a  dark  place. 

SULPHATE  OF  COPPER  : 

4.  A  crystal  of  Pure  Sulphate  of   Copper,  smoothly   pointed 
may  be  used  for  touching  granular  lids  of  old  standing. 

5.  Lapis  Divinus  : 

Sulphate  of  Copper  1, 
Alum  1, 

Nitrate  of  Potash  1. 

Fused  together,  and  camphor  equal  to  -^  of  the  whole  added. 
The  preparation  is  run  into  moulds  to  form  sticks.  It  should  be 
kept  in  a  stoppered  bottle. 

Largely  used  for  the  treatment  of  chronic  granular  lids. 
34 


398  APPENDIX. 

LEAD  LOTION  : 

6.  Liquor  Plumbi  Subacetatis  (B.  P.)  gj, 
Distilled  Water  Oj. 

(1  in  160.) 

Used  in  chronic  conjunctivitis,  when  the  cornea  is  sound,  and 
in  inflammation  of  the  eyelids  and  lachrymal  sac. 

SPIRIT  LOTION  : 

7.  Eectified  (or  Methylated)  Spirit  giv, 
Water  ^xvj. 

Used  as  an  evaporating  lotion  to  allay  or  prevent  inflammation 
of  the  wound  after  operations  on  the  eyelids. 

8.  Lead  and  Spirit  Lotion  : 

Spirit  Lotion  Oj, 

Liquor  Plumbi  Subacetatis  (B.  P.)  gij. 

Used  in  the  same  cases  when  there  is  no  fear  that  the  cornea  is 
abaded  or  ulcerated.  A  better  antiphlogistic  than  spirit  alone. 

MERCURY  : 

9.  Calomel  Powder  : 

Used  for  dusting  on  the  cornea  in  some  cases  of  ulceration.  It 
is  flicked  into  the  eye  from  a  dry  camel-hair  brush. 

10.  Yellow  Oxide  of  Mercury  ("Yellow  ointment,''1  "  Pagen- 

stecher's  ointment ") : 
Yellow  Oxide  of  Mercury  gr  iij, 
Vaseline  zj. 

(1  in  20.) 

11.  A  weaker  preparation,  containing  gr.  j  of  the  Yellow 
Oxide  to  gj  (1  in  60),  is  sometimes  useful. 

Used  in  many  cases  of  corneal  ulceration  and  recent  corneal 
nebulae,  a  morsel  as  large  as  a  hemp-seed  being  inserted  within 
the  lower  lid  by  means  of  a  small  brush  once  or  twice  a  day.  It 
is  also  suitable  for  ophthalmia  tarsi. 

12.  Yellow  Ointment  with  Atropine : 

Yellow  Oxide  of  Mercury  gr.  iij, 
Sulphate  of  Atropia  gr.  £, 
Vaseline  £j. 
Used  in  -the  same  way  as  10  and  11. 

13.  Red  Oxide  of  Mercury :. 

Red  Oxide  of  Mercury  gr.  iij, 

Vaseline  ^j. 

Used  for  ophthalmia  tarsi,  etc.  Was  formerly  used  for  corneal 
ulcers  and  nebulae;  but  the  yellow  oxide,  which  being  made  by 
precipitation  is  not  crystalline,  is  now  generally  preferred  because 
less  irritating. 


APPENDIX.  399 

14.  Nitrate  of  Mercury  (Citrine  Ointment}: 

Unguentum  Hydrargyri  Xitratis  (B.  P.)  gj, 
Vaseline  or  Prepared  Lard  3vij. 
Used  in  the  same  cases  as  13. 

SULPHATE  OF  ZINC: 

15.  Sulphate  of  Zinc  gr.  j  or  ij, 
Water  or  liose  Water  Jj. 

CHLORIDE  OF  ZINC: 

16.  Chloride  of  Zinc  gr.  ij, 
Water  5J, 

If  there  is  a  deposit,  add  of  Dilute  Hydrochloric 

Acid,  just  enough  to  make  a  clear  solution. 
ALTTM: 

17.  Alum  gr.  iv  to  gr.  x, 
Water  |j. 

The  above  lotions  are  in  common  use  in  the  milder  forms  of 
acute  and  chronic  ophthalmia.  The  chloride  of  zinc  occasionally 
irritates;  it  is  especially  used  in  purulent  and  severe  catarrhal 
ophthalmia  instead  of  the  weak  nitrate  of  silver  lotions.  The 
stronger  alum  lotion  is  often  used  in  the  same  cases.  The  alum 
and  sulphate  of  zinc  lotions  may  be  used  unsparingly  to  the 
conjunctiva;  the  chloride,  even  in  severe  cases,  not  more  than 
six  times  a  day. 

CARBONATE  OF  SODIUM: 

18.  Carbonate  of  Sodium  gr.  x, 
Water  I). 

Used  for  softening  the  crusts  in  severe  ophthalmia  tarsi.  A 
small  quantity  of  the  lotion,  diluted  with  its  own  bulk  of  hot 
water,  to  be  used  for  soaking  the  edges  of  the  eyelids  for  ten  or 
fifteen  minutes  night  and  morning. 

TAR  AND  SODA: 

19.  Carbonate  of  Sodium  giss, 

Liquor  Carbonis  Deterg^ens  gj  to  $ss, 
Water  to  Oj. 
Used  in  the  same  cases  as  the  last. 

BORAX: 

20.  Biborate  of  Sodium  gr.  x, 
Water  ^j. 

Used  in  the  same  cases  as  the  last. 

QUININE  LOTION  : 

21.  Sulphate  of  Quinine  gr.  iij, 

Acid  Sulph.  dil.  (B.  P.),  just  enough  to  dissolve, 
Water  gj. 
Used  in  diphtheritic  ophthalmia. 


400  APPENDIX. 


BORACIC  ACID  LOTION: 

22.  Boracic  Acid  4, 
Water  100  by  weight. 

Used  as  an  antiseptic  before  and  after  operations  on  the  eyeball, 
and  in  the  treatment  of  suppurating  ulcers  of  the  cornea. 

CARBOLIC  ACID  LOTION: 

23.  Absolute  Phenol  5, 
Water  by  weight  100. 

Used  in  purulent  ophthalmia.  It  is  very  important  to  use 
absolutely  pure  carbolic  acid  for  application  to  the  conjunctiva. 
Severe  irritation  often  follows  if  any  other  varieties  are  employed. 

MYDRIATICS  AND  MYOTICS  : 

24.  (1)  Strong  Atropine  Drops  : 

Liquor  Atropiae  Sulphatis  (B.  P.) 

(Sulphate  of  Atropia  gr.  iv, 

Distilled  water  ^j). 

Used  in  all  cases  where  the  rapid  and  full  action  of  the  drug  is 
required.  Atropine  (a  single  drop,  of  2  grains  to  5],  or  about 
.5  percent.)  begins  to  act  on  the  pupil  in  about  15  minutes,  and 
on  the  accommodation  a  few  minutes  later;  it  produces  full  dila- 
tation of  the  pupil  (9  mm.)  in  30  to  40  minutes,  and  full  paraly- 
sis of  accommodation  in  about  2  hours.  Both  remain  at  their 
height  for  24  hours,  and  the  effect  does  not  pass  off  entirely  till 
from  3  to  7  days,  the  accommodation  recovering  rather  sooner 
than  the  pupil.  If  stronger  solutions  be  used  several  times,  the 
action  continues  longer.  Atropine  is  absorbed  into  the  aqueous 
humor  and  acts  locally  vipon  the  iris.  The  effects  of  atropine  are 
only  very  temporarily  overcome  by  eserine. 

25.  (2)    Weak  Atropine  Drops  : 

Sulphate  of  Atropia  gr.  J, 

Distilled  water  gj. 

Used  when,  for  optical  purposes,  it  is  desired  to  keep  the  pupil 
dilated  for  a  long  time,  as  in  immature  nuclear  cataract.  A  single 
drop  about  three  times  a  week  will  generally  suffice.  Solutions  of 
sulphate  of  atropine  keep  for  an  indefinite  time;  the  flocculent 
sediment  which  often  forms  does  not  impair  their  efficiency.  The 
addition  of  1  part  of  carbolic  acid  to  1000  of  the  solution  is  said 
to  prevent  "atropine  irritation."  The  liquor  atropine  (B.  P.), 
which  contains  rectified  spirit,  is  irritating  to  the  eye  and  should 
not  be  used. 

26.  Daturine  : 

Sulphate  of  Daturia  gr.  iv 
Distilled  water  §j. 

Used  as  a  mydriatic  in  cases  where  atropine  causes  conjunctiva! 
irritation. 


APPENDIX.  401 


27.     Duboisine  : 


Sulphate  of  Duboisia  gr.  j. 
Distilled  water  gj. 

A  new  mydriatic,  acting  more  quickly  and  powerfully,  and 
passing  off  in  a  shorter  time,  than  atropine.  Is  tolerated  in  cases 
where  atropine  causes  conjunctivitis.  To  be  used  with  caution,  as 
well-marked  toxic  symptoms  are  sometimes  caused. 

Duboisine  begins  to  act  on  the  pupil  and  accommodation  in  less 
than  10  minutes,  produces  full  mydriasis  in  less  than  20  minutes, 
and  complete  cycloplegia  in  about  1  hour.  The  maximum  effect 
does  not  last  quite  as  long  as,  and  the  effect  passes  off  completely 
rather  sooner  than,  that  of  atropine.  Duboisine  seldom  breaks 
down  iritic  adhesions  which  have  already  resisted  atropine.  Ita 
chief  use  seems  to  be  for  cases  in  which  atropine  causes  irritation. 

28.  Homatropine  : 

Hydrobromate  of  Homatropine  gr.  iv, 
Distilled  water  3jj. 

A  new  mydriatic,  acting  rather  more  quickly  and  passing  off 
much  sooner  than  atropine;  very  convenient,  therefore,  for  di- 
lating the  pupil  for  ophthalmoscopic  examination. 

Homatropine  begins  to  act  on  the  pupil  and  accommodation  in 
from  5  to  10  minutes;  the  greatest  dilatation  of  pupil  (usually, 
however,  rather  less  than  that  obtained  by  atropine)  is  reached  in 
about  35  minutes,  and  complete,  or  nearly  complete  cycloplegia 
in  an  hour  or  rather  less  (with  a  solution  of  gr.  iv  to  ^j).  The 
greatest  effect  is  only  maintained,  however,  for  an  hour  or  two, 
and  both  pupil  and  accommodation  usually  recover  completely  in 
24  hours  or  less. 

29.  Eserine  (the  Alkaloid  of  Calabar  Bean) : 

Sulphate  of  Eseria  gr.  iv, 

Distilled  water  ^j. 

Used  in  mydriasis  and  paralysis  of  the  accommodation  whether 
caused  by  atropine  or  by  nerve  lesions,  in  some  forms  of  corneal 
ulcer,  and  in  acute  glaucoma. 

30.  A  weaker  solution  (gr.  j  to  ^j)  is  often  better  borne. 

Eserine  begins  to  act  on  the  pupil  and  accommodation  in  about 
5  minutes;  its  maximum  effect  is  reached  in  15  to  30  minutes. 
Its  effect  on  the  accommodation  lasts  only  an  hour  or  two,  but  the 
pupil  does  not  completely  recover  for  many  hours,  sometimes  2  or 
3-  days.  After  several  weeks'  use  the  effects  last  longer,  but  never 
as  long  as  those  of  atropine.  A  very  weak  solution  acts  only  on 
the  pupil,  not  on  the  accommodation.  Eserine  causes  pain  in  the 
eye  and  head,  and  twitching  of  the  orbicularis ;  the  pain,  some- 
times severe,  seldom  lasts  long. 

All  the  mydriatics  and  myotics  may  be  obtained  in  the  form  of 
34* 


402  APPENDIX. 

small  gelatine  disks  of  known  strength  (made  by  Savory  and 
Moore),  which  are  sometimes  more  convenient  than  the  solutions. 
Of  the  mydriatics,  homatropine  and  duboisine  are  much  the  most 
expensive  (about  Is.  6d.  a  grain).  Eserine  sulphate  is  also  expen- 
sive (about  Is.  a  grain).  Atropine  sulphate  costs  rather  more  than 
Id.  a  grain. 

31.  Belladonna  Fomentation  : 

Extract  of  Belladonna  ^j  to.^ij, 
Water  Oj. 

Warmed  in  a  cup  or  small  basin  and  used  as  a  hot  fomentation 
in  suppurating  and  serpiginous  ulcers  of  cornea. 

32.  Pilocarpine for  Subcutaneous  Injection: 

Hydrochlorate  of  Pilocarpine  gr.  v, 

Distilled  water  gj. 

Dose,  3  minims,  gradually  increased,  to  be  injected   daily  or 
less  often. 
Used  in  cases  of  retinal  detachment,  choroiditis,  and  retinitis. 

32A.     Pilocarpine  Drops,  gr.  iv.  to  ^j. 

Pilocarpine  is  a  myotic  like  eserine,  but  its  action  is  much 
weaker. 

33.  STRYCHNIA /or  Subcutaneous  Injection: 

Liquor  Strychnise  (B.  P.)  gr.  iv,  to  ^j. 

Dose,  2  minims  (•£$  grain),  gradually  increased,  for  subcutaneous 
injection.  To  be  injected  once  a  day. 

IODOFORM. — This  substance  seems  likely  to  be  of  real  service  in 
some  forms  of  ophthalmia,  especially  in  purulent,  gonorrhceal, 
and  granular  cases.  It  is  reported  to  arrest  discharge  more 
quickly  than  nitrate  of  silver,  and  its  application  is  certainly 
far  less  painful.  It  may  either  be  dusted  with  a  brush  on  the 
everted  lids  once  a  day,  or  used  as  an  ointment  made  with 
vaseline.  The  iodoform  must  be  very  finely  powdered,  or  its 
crystals  will  cause  mechanical  irritation.  Mr.  Jennings  Milles, 
house-surgeon  at  Moorfields,  tells  me  that  he  finds  an  ointment 
of  gr.  xv  to  ^j  a  convenient  strength  for  most  cases.  At  the  last 
Ophthalmological  Congress  at  Heidelberg  the  strength  advised 
was  gr.  xxx  to  ^j.  I  have  not  yet  used  iodoform  enough  to  draw 
any  conclusions. 

DISEASES  OF  CANALICULUS. — The  canaliculus  is  occasionally 
plugged  by  the  growth  in  it  of  a  mycelial  fungus,  which  mingled 
with  pus  cells  and  mucus  forms  a  yellowish,  or  greenish,  putty- 
like  concretion.  These  masses  sometimes  calcify,  and  are  then 
called  "  dacryo-liths." 

34.  BANDAGES  for  the  eyes  may  be  of  thin  flannel  or  soft 
calico.    A  linen  or  knitted  cotton  bandage,  about  ten  inches  long, 


APPENDIX.  403 

•with  four  tails  of  tape,  or  a  loop  of  tape  embracing  the  back  of 
the  head  (Liebreich's  bandage),  is  very  convenient  after  the  more 
serious  operations.  An  ordinary  narrow  llannel  bandage  is  better 
when  much  pressure  is  wanted,  or  if  the  patient  be  unruly. 

When  absolute  exclusion  of  light  is  desired,  it  is  best  to  use  a 
bandage  made  of  a  double  fold  of  some  thin  black  material. 

Fine  old  linen  is  better  than  lint  for  laying  next  the  skin  in 
dressings  after  operations. 

35.  SHADES  may  be  made  of  thin  cardboard  covered  with 
some  dark  material,  or  of  stout  dark-blue  paper,  like  that  used  for 
making  grocers'  sugar  bags.     Shades  of  black  plaited  straw  are 
also  very  light  and  convenient. 

Shades,  to  be  effectual,  should  extend  to  the  temple  on  each 
side,  so  as  to  exclude  all  side  light. 

36.  PROTECTIVE  GLASSES  : 

Various  patterns  of  glasses  are  made  for  the  purpose  of.  pro- 
tecting the  eyes  from  wind,  dust,  and  bright  light.  The  glasses 
are  either  flat  or  hollow  like  a  watch  glass,  and  are  colored  in 
various  shades  of  blue  or  smoke  tint.  The  most  effectual  are  the 
ones  known  as  "goggles;  "  in  these  the  space  between  the  glass 
and  the  edge  of  the  orbit  is  filled  by  a  carefully  fitting  framework 
of  fine  wire  gauze  or  black  crape,  by  which  side-wind  and  light 
are  excluded.  A  small  air-pad  of  thin  India-rubber  tubing  makes 
the  frame  fit  still  more  closely. 

Other  forms,  known  as  "horseshoe  "  or  "  D,"  and  "domed  "  or 
"  hollow,"  glasses  are  also  in  common  use. 

38.  OPHTHALMOSCOPES  : 

It  is  impossible  to  say  that  any  ophthalmoscope  is  the  best. 
When  expense  is  not  a  great  object  it  is  always  better  to  have  one 
of  the  so-called  "refraction  ophthalmoscopes."  In  these  a  num- 
ber of  small  lenses  are  placed  in  a  disk  behind  the  mirror,  the 
disk  being  made  to  revolve  by  the  pressure  of  the  finger  against 
its  edge  so  as  to  bring  the  lenses  one  after  another  opposite  the 
sight-hole.  The  use  of  the  lenses  is  explained  at  p.  75.  For 
medical  ophthalmoscopy  it  is  not  essential  to  have  so  many 
lenses  ;  about  four  concave  and  two  convex  will  enable  an  erect 
image  to  be  easily  obtained  in  most  cases.  Liebreich's  "small" 
ophthalmoscope  and  Oldham's  ophthalmoscope  are  both  very 
convenient  forms  for  general  use,  and  cost  less  than  half  as  much 
as  the  refraction  instruments. 

Of  the  refraction  ophthalmoscopes  there  are  now  a  great  many 
patterns  differing  in  the  number  and  size  of  the  lenses,  the  size 
of  the  mirror  and  lens-bearing  disk,  and  other  details.  Usually 
the  disk  contains  20  to  24  lenses,  and  one  empty  circle.  In  the 
simpler  forms  about  half  the  lenses  are  -f-  and  half  • — .  But  in 
others  the  number  of  powers  is  immensely  increased  by  combining 
lenses  of  different  strengths,  e.g.,  the  disk  may  contain  24  + 
lenses,  whilst  a  single  movable  —  lens,  rather  stronger  than  the 


404  APPENDIX. 


highest  -f-  is  placed  behind  the  disk  over  the  sight-hole;  by  using 
it  alone  or  placing  it  in  succession  over  the  various  -f-  lenses  a 
series  of  25  —  powers,  or  49  in  all,  will  be  obtained.  In  order  to 
avoid  the  error  caused  by  looking  obliquely  through  a  lens,  some 
of  the  more  elaborate  instruments  (Loring's,  Couper's,  Fox's,  e.  g.) 
are  so  arranged  that  the  mirror  can  be  sufficiently  inclined  to  re- 
ceive the  light  whilst  the  lens-bearing  disk  remains  at  right  angles 
to  the  observer's  line  of  sight.  Generally  speaking,  the  English 
and  American  instruments  are  much  better  made  than  the  French. 
Of  the  simpler  forms,  the  one  introduced  by  Dr.  Gowers  is  in  my 
experience  (with  one  or  two  minor  alterations)  very  convenient 
and  efficient.  Of  the  more  expensive  forms,  an  instrument  lately 
introduced  by  Mr.  "Webster  Fox,  late  house-surgeon  at  Moorfields, 
is  undoubtedly  one  of  the  best,  both  the  design  and  the  workman- 
ship being  extremely  good.  In  a  good  refraction  ophthalmoscope 
the  mirror  should  be  thin  and  the  sight-hole  perforated  ;  the  lens- 
disk  thin  and  working  as  close  to  the  back  of  the  mirror  as  pos- 
sible;  the  lenses  evenly  mounted,  centred  truly,  easily  accessible 
for  cleaning,  and  not  less  than  5  mm.  in  diameter. 


INDEX. 


ABBREVIATIONS,  13 
Abscess  of  cornea,  117 
episcleral,  146 
of  lachrymal  gland,  89 

sac,  92 

orbital,  159,  280 
Abrasion  of  cornea,  164 
Accommodation,     examination, 

44 

errors  of,  287 
in  myopia,  296 
influence  of  age,  317 

refraction,  317 
paralysis  of,  329,  375 
relative,  45 
spasm  of,  290 
Accommodative  asthenopia,  244, 

301 

Acuteness  of  sight,  27 
Albinism,  202 

Albuminuric  retinitis,  207,  215 
Alcohol  amblyopia,  242,  380 
Amaurosis      (blindness     without 
visible   changes  in  any  part 
of  the  eye;    also  applied  to 
blindness  from  optic  or  ret- 
inal atrophy),  238 
Amblyopia  (defective  sight  with- 
out visible  changes;  also  from 
haze  of  media  and  optical  de- 
fects), 238 
alcohol,  242,  380 
from  defective  images,  239 

suppression,  238 
hysterical,  244 
pctatorum,  380 
tobacco,  241,  380 
Ametropia  (any  permanent  error 

of  refraction  of  the  eye),  287 
Anisometropia  (unequal  refrac- 
tionin  the  two  eyes),  316 


Anterior  focus  of  eye,  26 
polar  cataract,  174,  175 
staphyloma,  148 
Apparent  size  of  objects,  45 
Arcus  senilis,  132 

inflammatory,  133 
Artificial  pupil,  354 
Asthenopia  (weakness   of  eyes: 
eyes    that    cannot    be    used 
for  long.     See  also  Hyper- 
metropia,  Myopia,  Ambly- 
opia.). 

accommodative,  244,  301 
muscular,  244,  300 
retinal,  244 
Astigmatism,  308 

measurement   by   ophthalmo- 
scope, 76 
traumatic,  164 
Atrophy  of  optic  disk  (see  also 

Neuritis),  232 
clinical  aspects,  234 
local  causes,  233 
primary,  235 
progressive,  235 
with     spinal    disease,    236, 

390 

choroid,  190 
retina,  210,  221 
Atropine  for  examination  of  eye, 

61,  66,  400 

effects  on  tension,  119,  267 
in  cataract,  182 

corneal  ulcers,  122,  123 
glaucoma,  267 
iritis,  141 
irritation,  103 
Axis,  optic,  of  eye,  33 
principal,  17 
secondary,  17 
visual,  26 

(  405  ) 


406 


INDEX. 


BANDAGES,  402 

Bandaging  in  iritis,  142 
ophthalmia,  100 
suppuration  after  cataract  ex- 
traction, 185 
ulcers  of  cornea,  122 

Basedow's  disease  (see  Goitre). 

"  Black  eye,"  158 

Blennorrhcea  of  conjunctiva,  95 

Blepharitis,  81 

Blepharospasm  (spasmodic  clos- 
ure of  eyelids),  112 

Blindness  of  one  eye,  undiscov- 
ered, 240 

Bloodvessels  of  eye,  external,  35 
retina,  203 

Blows  on  eyeball,  161 

Brain  (see  Cerebral). 

Burns  of  eye,  165 

CANALICULI,  disease,  91 

Can  thus,  section  of,  in  blepharo- 

spasm, 121 
Cataract,  171 

anterior  polar,  175 

atropine  in,  182 

choroidal  changes  with,  200 

concussion,  180 

congenital,  180 

cortical,  172,  178 

diabetic,  172,  382 

diagnosis,  176 

discission,  182 

dotted  cortioal,  173 

extraction,  182,  362 

glasses,  186 

hard,  172 

lamellar,  173,  178,  186,  393 

mixed,  172 

Morgagnian,  181 

nuclear,  172,  177 

operations  for,  182,  362 

over-ripe,  183 

posterior  polar,  175,  178 

primary,  175 

prognosis,  181 

pyramidal,  173 

secondary, 175,  187 

sight  after  removal,  186 

soft,  171 

solution,  182 


Cataract,  suction,  183 

symptoms  of,  175 

traumatic,  180 

treatment  of,  182 

zonular  (see  Lamellar;. 
Catarrhal  ophthalmia,  99 
Caustics,  injuries  by,  165 
Cellulitis  of  orbit,  159,  395 
Central  scotoma,  241 
Centre  of  movement  of  eye,  26 
Cerebral  tumors,  neuritis  in,  388 

syphilis,  389 

Cerebritis,  neuritis  in,  389 
Chalazion  (Meibomian  cyst),  84 
Chancre  of  eyelid,  87,  373 
Chemosis   (oedema  of  the  ocular 

conjunctiva,    either  passive  or 

inflammatory),  96 
Choked  disk,  226 
Cholesterine  in  vitreous,  253 
Choroid,  appearances  in  health, 

189 
in  disease,  190 

atrophy,  190 

colloid  disease,  195 

coloboma,  202 

congestion,  201 

diseases,  188 

exudation,  194 

hemorrhage,  195,  196,  201 

myopic  changes,  199 

rupture,  195 

sarcoma,  283 

tubercle,  194,  286 
Choroidal  disease  with  cataract, 

200 
Choroiditis,  central,  199 

disseminata,  197 

in  hydrocephalus,  390 

senile,  199 

syphilitic,  194,  197,  374 

unclassed  or  anomalous,  201 
Chronic  ophthalmia,  109 
Ciliary  congestion  (see  Conges- 
tion). 

muscle,  paralysis  of,  163,  329 

region,  diseases  of,  145 
Cold  in  iritis,  143 
Color  blindness,  235,  248 

defect  in  amblyopia,  241 

perception,  249 


INDEX. 


407 


Color  perception,  examination, 

45,  249 

of  railroad  employes,  47 
Coloboma  of  choroid  (congenital 

cleft  in  choroid),  201 
of  iris    (cleft  in   iris    usually 
restricted   to   the  congenital 
form,  but  sometimes  applied 
to  the  cleft  made  by  iridec- 
tomy),  144,  355 
"Commotio  retince,"  164 
Congenital  absence  of  iris,  144 
cataract,  180 

coloboma  (see  Coloboma). 
dermoid  cyst,  275 

tumor,  277 

nbro-fatty  growth,  277 
irideremia,  144 
ptosis,  88 

Congestion,  ciliary,  37,  112,  134 
circumcorncal,  134 
cboroidal,  201 
conjunctiva!,  38 
episcleral,  38 
of  optic  disk,  206,  226 
retinal,  206 
Conical  cornea,  124 
Conjunctiva,  diseases,  95 
burns  and  scalds,  165 
epithelioma,  277 
growths,  275 

Conjunctivitis  (see  Ophthalmia). 
Convulsions  and  lamellar  cata-  | 

ract,  393 

Coredialysis  (separation  of  iris 
from  its  ciliary  attachment), 
162 

Cornea,  abrasion,  1G4 
abscess,  117 
diseases  of,  110 
ulceration,  111 
atropine,  122,  123 
eserine,  123 
fomentation,  122 
iridectomy,  123 
iritis  in,  117 
paracentesis,  123 
phlyctenuiar,  113 
recurrent  vascular,  115 
serpiginous,  116 
suppurating,  117 


Cornea  ulceration,  treatment,  119 

examination,  30 

lead  deposit  ou,  133 

transverse  calcareous   opacity 

of,  131 

Corneal  disease,  seton  for,  121, 
129 

section  for  ulcer,  123 
Cortical  cataract,  172,  177 
Crescent,  myopic,  199,  292 
Croupous  ophthalmia,  101 
Cupping   of  disk   in  glaucoma, 

258,  260 

Cutaneous  horn,  85 
Cyclitis,  149,  151 

traumatic,  151 
Cyclo-iritis  (see  Sclero-). 

keratitis  (see  Sclero-). 
Cycloplegia  ( paralysis  of  ciliary 

muscle),  163,  329 
Cysticercus  in  eye,  254,  387 
Cvstic  tumors  in  lids  and  orbit, 

277 
Cysts  of  iris,  286 

lymphatic,  of  conjunctiva,  276 

DACRYO-CYSTITIS  (inflammation 

of  the  lachrymal  sac),  92 
Dacryo-lith,  402 
Dacryops  (cystic  distention  of  one 

or  more  ducts  of  the  lachrymal 

gland),  90 
"Dangerous  region,"  167 

zone,  152 
Decentred  lens,  23 
Dermoid  cysts  of  eyebrow,  275 

tumor  of  eyeball,  277 
Detachment  of  iris,  lt>2 

of  retina,  162,  211,  255,  382 
Diabetes,  diseases  from,  382 
Dioptre,  28 

Diphtheria,  diseases  from,  376 
Diphtheritic  paralysis  of  accom- 
modation, 377 

ophthalmia,  101 

Diplopia  (seeing   two   images   oj 
the  same  object),  33 

binocular,  33 

crossed,  322 

homonymous,  322 

in  locomotor  ataxia,  391 


408 


INDEX. 


Diplopia  in  meningitis,  391 
uniocular    (double   sight   with 

one  eye),  33 

Direct  examination,  63,  72 
Dislocation  of  lens,  162,  187 
Disseminated  choroiditis,  197 
Distichiasis   (double  row  of  eye- 
lashes, lashes  displaced  and  di- 
vided into  two  rows  by  distor- 
tion of  edge  of  lid),  108 
Dry  heat  in  iritis,  142 

ECHINOCOCCUS  in  orbit,  387 

Ectropion,  338 

Eczema  of  eyelids,  82 

Embolism  of  retinal  artery,  218 

Emmetropia,  E.  (the  refractive 
condition  of  the  normal  eye  with 
accommodationrelaxed;  paral- 
lel rays  focussed  upon  the  ret- 
ina), 25,  287 

Emphysema  of  orbit,  158 

Endemic  nyctalopia,  247 

Entozoa  in  eye,  387 

Entropion,  organic,  108,  335 
spasmodic,  334 

Epicanthus,  88 

Epiphora  (watery  eye,  tears  How- 
ing  over  edge  of  lid),  82,  90 

Episcleritis  (inflammation,  usu- 
ally localized,  of  the  tissue  be- 
tween the  sclerotic  and  conjunc- 
tiva), 116,  145 

Epithelial  tumor  of  iris,  286 

Epithelioma  of  conjunctiva,  277 

Erysipelas,  conjunctiva  in,  101 
optic  atrophy  from,  395 

Eserine,  effect  on  tension,  268 
in  corneal  ulcer,  123 
glaucoma,  268 
mydriasis,  395 
irritation,  103 

Examination  by  focal  light,  60 
by  ophthalmoscope,  62,  73 
of  bloodvessels  of  eye,  35 
color-perception,  45,  249 
cornea,  30 
field  of  vision,  40 
mobility  of  eye,  31 
pupil,  40 


Examination  of  tension,  30 
Excision  of  eye  in  sympathetic 
affections,  155,  156 

for  injury,  167,  170 
"Exclusion  "  of  pupil,  137,  139 
Exophthalmic  goitre,  395 
External  examination  of  eye,  30 
Extraction  of  cataract,  182 
Eyelids,  diseases  of,  81 

chancre  on,  87 

lupus  on,  87 

ulcers  on,  86 

syphilitic  disease  of,  87 

FACIAL  nerve,  paralysis,  90,  394 
False  image,  322 
Far-point,  44 
Feigned  blindness,  25 
Fibro-fatty  congenital   growth, 

277 

Field  of  vision  (see  Vision). 
Fifth  nerve,  herpes,  267 

influence  on  tension,  393 

injury  to,  causing  amaurosis, 
388 

paralysis,  267,  393 
Flittering  scotoma,  387 
Fusion  power  of  ocular  muscles, 

24 

Focal  illumination,  60 
Focus,  anterior,  of  eye,  26 

conjugate,  18 

principal,  17,  18 

virtual,  19 
Fomentation   in   corneal   ulcer, 

122 
Foreign  body  in  eyeball,  168, 170 

in  orbit,  160 

on  cornea,  164 
Fovea  centralis,  71,  204 
Frontal  sinus,  distention,  279 
Functional  night  blindness,  246 
Fundus  of  eye,  appearances,  66 

definition,  64 
Fungus  in  canaliculi,  402 

GELATINOUS  exudation  in  ante- 
rior chamber,  135 
General  diseases  causing  eye  dis- 
ease, 373 


INDEX. 


409 


General  paralysis  of  insane,  391 
Giddiness  from  ocular  paralysis, 

328 
Glaucoma,  256, 

absolute,  260 

acute,  256,  259 

after   extraction   of   cataract, 
272 

cases  for  operation,  270 

causes,  264,  266 

chronic,  257 

corneal  changes  in,  131 

from  anterior  synechia,  273 
intraocular  tumor,  284 

fulminans,  260 

hemorrhagic,  274 

in   sympathetic  ophthalmitis, 
154 

malignum,  272 

operations  for,  268,  355 

premonitory  stage,  257 

primary,  256 

remittent,  259 

second  operations  in,  272 

secondary,  256,  273 
to  iritis,  139,  386 

simplex,  258 

subacute,  258 

theory  of  iridectomy,  268 
Glaucomatous  cup,  258,  260 
Glioma  of  retina,  282 
Goitre,  exophthalmic,  395 
Gonorrhceal  ophthalmia,  95 

rheumatism,  iritis  from,  385 
Gout,  diseases  in,  385 
Gouty  cyclitis,  150 

iritis,  140 

Granular  ophthalmia,  103 
Granuloma,  286 
Graves'  disease  (see  Goitre). 
Gunshot  injuries,  166 

HEMORKHAQE,    choroidal,    194, 

196,  201,  293 
into    anterior    chamber,    135, 

161 

optic  nerve,  219 
intraocular,  163 
retinal,  208,  379 
secondarv,  after  iridectomy, 

360 


Hemorrhagic  glaucoma,  274 

Hard  cataract,  172 

Heart  disease,  eye  diseases  from, 

383 
Hemeralopia    (day  sight,   term 

applied  to  cases  where  sight  is 

especially   defective    at    night, 

night-blindness),  247 
Hemianopsia  or  Hemiopia  (half 

sight,   any    condition    causing 

loss  of  one-half  of  the  visual 
field),  243 
Hereditary  amblyopia,  241 

disease  of  retina,  222 

syphilis,  eye  diseases  in,  375 
Herpes,  cornece,  113 

zoster,  393 
Homonymous  diplopia  (see  Di- 

plopia). 
Hyalitis  (inflammation  of  vitreous 

(see  Vitreous). 
Hydatid  in  orbit,  387 
Hydrocephalus  choroiditis,  390 

optic  atrophy,  390 
Hyperaesthesia  of  retina,  244 
Hypermetropia     H.    (refractive 
condition  in  which  the  retina 
lies   in   front    of  principal 
focus),  299 

acquired,  300 

haze  of  disk  in,  206 

how  to  measure,  305 

measurement   by   ophthalmo- 
scope, 75 
Hyphaema  (blood  in  lower  part 

of  anterior  chamber),  135 
Hypopyon  (pus  in  the  lower  part 
of  the  anterior  chamber),  117 

in  iritis,  139 
Hysterical  amaurosis,  243 

amblyopia,  243 

ICE-BLINDNESS,  247 
Idiopathic  phthisis  bulbi,  150 
Images  formed  by  lenses,  19,  20 
size  of,  in  relation  to  object, 

20 
retinal,  influence  of  lenses  on, 

26 

Indirect  examination,  62,  64 
Inflammatory  glaucoma,  258 


35 


410 


INDEX. 


Injuries  of  parts  around  eye,  258 

eyeball,  161 
Insufficiency   of  internal   recti, 

298,  323 
Intraocular  tumors,  282 

hemorrhage,  163 
lodoform,  402 

Iridectomy    (cutting  out  a  piece 
of  iris),  355 

exciting    glaucoma    in    other 
eye,  267 

for  glaucoma,  267,  355 

in  corneal  ulcer,  123 

in  iritis,  143 

Irideremia  (absence  of  iris),  con- 
genital, 143 

Irido-choroiditis,  140,  149 
Irido-cyclitis,  traumatic,  168 
Iridodesis,  355 
Iridoplegia    (paralysis  of  iris), 

329 
Iridotomy  or  Iritomy  (incision 

of  iris,  356 
Iris,  color,  38 

diseases  of,  134 

cyst,  286 

epithelial  tumor,  286 

in  health,  38 

granuloma,  286 

paralysis,  329 

sarcoma,  286 

tremulous,  162 
Iritis,  134 

atropine  in,  141 

chronic,  140 

cold  in,  143 

dry  heat  in,  142 

glaucoma  secondary  to,  139, 
386 

gouty,  140,  385 

heredito-gouty,  140,  386 

in  corneal  ulcer,  117 

interstitial  keratitis,  125 

iridectomy  in,  143 

leeches  in,  141 

paracentesis  in,  142 

pupil  in,  136 

recurrent,  139 

results  of,  138 

rheumatic,  139,  385 

serous,  149,  154 


Iritis,   "spongy"  exudation  in, 
135 

sympathetic,  151 

syphilitic,  139,  373 

traumatic,  140,  143,  164,  185 
Ischtemia  of  disk,  226 

of  retina,  220,  378 
Ivory  exostosis,  279 

KEKATITIS  (inflammation  of  cor- 
nea), 110 

interstitial,  125 
iritis  in,  125 

marginal,  113 

parenchymatous,  125 

punctatd,  130,  149,  154 

secondary  forms,  130 

strumous,  125 

syphilitic,  125,  129,  374 
Keratoscopy,  77 
Kidney  disease,  eye  in,  382 

LACHRYMAL  diseases,  89 

canaliculi,  alterations,  91 

gland,  abscess,  89 
inflammation,  89 

obstruction,  90 

punctum,  alterations,  90,  402 

sac,  diseases,  91 
abscess,  92 

stricture,  342 
Lachrymation,  90 
Lamellar  cataract,  173, 178,  186, 

393 

Lamina  cribrosce,  69,  77 
Lead  deposit  on  cornea,  133 

optic  neuritis,  380 
Leeches  in  iritis,  141 
Lens,flaws  in, preceding  cataract, 
173 

senile  changes  in,  171 
Lenses,  decentred,  23 

definition,  16 

deviation  by,  16 

influence  of,  on  size  of  retinal 
image,  26 

siscns  for  convex  and  concave, 
28 

spectacle,  table  of,  29 
Lenticular  ganglion  disease.  331 
Leucocythaemic  retinitis,  383 


INDEX. 


411 


Leucoma  (a  patch  of  dense  opac- 
ity of  cornea),  111 

Lice  on  eyelashes,  86 

Lime-burn,  165 

Lippitudo  (eversion  with  rawness 
of  the  edge  of  the  lid,  usually 
the  result  of  severe  ophthalmia 
tarsi),  82 

Locomotor   ataxia,  cycloplegia, 

391 

diplopia,  391 
iridoplegia,  391 
optic  atrophy,  235,  390 

Lupus,  conjunctival,  275 
of  eyelid,  87 

Lymphatic  cysts  of  conjunctiva, 
276 

Macula  lutea,  71 

Magnet  for  removing  iron  from 

eye, 168 
Malarial  fevers,  diseases  from, 

378 

Malignant  tumors  (see  Tumors). 
Malingering,  247 
Marginal    keratitis,     113,     115, 

127 

Measles,  diseases  from,  378 
Megalopsia,  247 
Megrim,  eye  symptoms,  387 
Meibomian  concretions,  85 

cyst,  84 

Membranous  ophthalmia,  101 
Meningitis,    epidemic    cerebro- 
spinal,  disease  in,  379 

neuritis  in,  389 

recovery  with  optic  atrophy, 
390 

syphilitic,  389 

tubercular,  389 
Micropsia,  247 

Mobility  of  eye,  examination,  31 
Molluscum  contagiosum,  85 
Moon-blindness,  246 
Morgagnian  cataract,  181 
Mucocele  (chronic  inflammation 

and    distention    of   lachrymal 

sac),  92 

Muco-purulent  ophthalmia,  99 
Muscae  volitantes  (small  moving 

specks  in  visual  field),  247 


Muscular  asthenopia,  300 
Mydriasis  (persistent  dilatation 

of  pupil),  39 
from  blow,  163 
paralytic,  327,  329 
Myopia,  288 

accommodation  in,  391 
choroidal  changes  in,  199 
crescent,  292 
from  conical  cornea,  298 
incipient  cataract,  298 
measurement  by   ophthalmo- 

scope, 76 
traumatic,  164 
treatment,  295 
Myosis  (persistent  contraction  of 

pupil),  paralytic,  394 
spinal,  391 


of  eyelids,  275 
Nasal  duct,  diseases,  91 
Near-point,  44 
Nebula  (a  faint  localized  opacity 

of  corned),  111 

Neuralgia  preceding  glaucoma, 
388 

neuritis,  388 

dimness  of  sight  in,  388 
Nerve,  facial,  paralysis,  90,  399 
Neuritis,  optic,  appearances,  227 

causation,  164,  231,  388 

cerebritis,  389 

intracranial  tumor,  389 

lead,  380 

meningitis,  389 

orbital,  disease,  231 

peripheral,  231,  240 

recovery  from,  228 

retrobulbar,  231,  240 

sight  in,  229 

syphilis,  375 
Neuro-retinitis,  320 
Neurotomy,  optico-ciliary,  350 
Night-blindness,  220,  246 
Nitrate  of  silver  in  corneal  ulcer, 
120 

in  ophthalmia,  98,  99 

staining  of  conjunctiva,  133 
Nodal  point  of  the  eye,  25 
Nuclear  cataract,  172,  177 
Nyctalopia,  220 


412 


INDEX. 


Nystagmus  (rapid  small  oscilla- 
tory movements  of  eyeball, 
involuntary  or  but  slightly 
under  control),  332 

in  disseminated  sclerosis,  392 

miners',  832 

OBLIQUE  illumination,  60 
Occlusion  of  pupil,  138,  139 
Ocular  paralysis,  320 

causes,  330 
Onyx    (accumulation   of  pus   in 

layers  of  cornea  ;  should  be  re- 
stricted to  cases  where  the  pus 

has  sunk  to  lowest  part  of  cor- 
nea), 118 

Opaque  nerve  fibres,  205 
Operations,  333 

for  abscess  of  orbit,  159 

abscission  of  eye,  349 

artificial  pupil,  354 

canthoplasty,  340 

cataract,  361 

causes  of  failure,  184 
after  operations,  186,  368 
extraction,  361 
needle,  370 
solution,  370 
suction,  371 

distended  frontal  sinus,  279 

division  of  canthus,  340 

ectropion,  338 

entropion,  organic,  335 
spasmodic,  334 

epilation,  333 

eversion  of  eyelid,  333 

excision  of  eye,  348 

foreign  body  on  cornea,  350 

inspection  of  cornea  in  photo- 
phobia, 334 

iridectomy,  355,  357 

iridodesis,  355 

iridotomy,  356 

lachrymal  abscess,  92,  341 
stricture,  342 

Meibomian  cyst,  333 

paracentesis  of  anterior  cham- 
ber, 352 

peritomy,  340 

ptosis,  340 

sclerotomy,  360 


Operations,  slitting  canaliculug, 

341 

strabismus,  343,  347 
trichiasis,  335 
readjustment,  347 
lachrymal,  341 
on  cornea,  350 
on  eyelids,  333 
iris,  354 

Ophthalmia  after  exanthems,  100 
catarrhal,  99 
chronic,  109 
croupous,  101 
diphtheritic,  101,  377 
follicular,  104 
from  atropine,  103 

cold,  101 

eserine,  103 

irritants,  101 
gonorrhceal,  95 
granular,  103 
impetiginous,  101 
in  eczema,  101 

erysipelas,  101,  395 

herpes  zoster,  101,  393 

schools,  101,  105 
membranous,  101,  377 
muco-purulent,  99 
neonatorum,  95 
pblyctenular,  113 
purulent,  95 
pustular,  113 
tarsi,  81 

Ophthalmitis,  sympathetic,  151 
Ophthalmoplegia  externa,  328 

interna,  330 
Ophthalmoscopes,  403 
Ophthalmoscopic     examination, 

62 
Optic  disk,  atrophy,  232 

congestion,  206,  226 

in  health,  68 
nerve,  disease  of,  224 

disease  from  syphilis,  375 

pathological  changes,  224 

tumors  of,  281 

neuritis  from  blows  on  eye,  164 
Optical  outlines,  13 
Orbit,  abscess,  159 
cellulitis,  395 
emphysema  of,  158 


INDEX. 


413 


Orbit,  foreign  bodies,  160 
hydatid,  387 
node,  282 
tumor,  278 
wound,  160 

PANNUS     (extensive    superficial 
,         vascularity  of  cornea),  107 

phlyctenular,  115 

trachomatous,  107 
Panophthalmitis,  140,  151 
Papilla  optica,  224 
Papillitis  (inflammation  of  optic 

disk),  see  Neuritis. 
Papillo-retinitis,  214 
Paracentesis  for  corneal  ulcer, 123 

in  glaucoma,  272 

iritis,  142 

Parallactic  movement,  212 
Paralysis     of    external     ocular 
muscles,  320,  391 

ciliary  muscle,  329 

facial  nerve,  90,  394 
'fifth  nerve,  267,  394 

fourth  nerve(superior  oblique), 
326 

internal  ocular  muscles,  329 

iris,  329,  391 

sixth  nerve  (external  rectus), 
325 

sympathetic  nerve,  394 

third  nerve,  327,  391 
Parasites,  254 
Pediculus  pubis,  86 
Perimeter,  41 
Peritomy,  108 

Pernicious  anaemia,  retinitis,  383 
Persistent  pupillary  membrane, 

144 
Phlyctenular  affections,  113 

pannus,  115 
Photophobia      (intolerance      of 

light),  112 

Physiological  cup,  69 
Pinguecula,  276 
Pigment  on  choroid,  192,  201 

in  retina,  192 
Plastic  iritis,  140,  154 
Polyopia  uniocularis  (seeing  sev- 
eral images  of  the  same  object) , 

176 


Polypi,  lachrymal,  92 
Posterior    polar    cataract,    175, 
178 

staphyloma,  199 

synechia,  134 

total,  137,  139 

Preliminary  iridectomy,  364 
Presbyopia,  316 

table,  319 

Primary  optic  atrophy,  234 
Prism,  14 
Prisms,  uses  of,  22 
Progressive  optic  atrophy,  234 
Projection,  15 
Prolapse  of  iris  (protrusion  or 

inclusion  of  iris  in  a  perforat- 
ing wound  of  cornea),  185 
Proptosis,  34 

in  orbital  disease,  89, 158,  264, 

280 

Protective  glasses,  403 
Pterygium,  276 

Ptosis  (falling  of  upper  eyelid), 
congenital,  88 

from  granular  lids,  108 

paralytic,  327 

traumatic,  159 

Pulsation,  retinal,  in  aortic  dis- 
ease, 383 

glaucoma,  383 
Punctum  proximum,  44 

remotum,  44 

Pupil  (see  also  Iris,  Synechia), 
examination,  39 

exclusion,  137,  139 

in  optic  atrophy,  234 
Pupil  in  optic  neuritis,  232 
iritis,  136 

influence  of  size  on  sight,  27 

occlusion,  138,  139 

total  posterior  synechia,   137, 
139 

why  black,  62 
Pupillary  membrane,  persistent, 

144 
Purpura,    retinal    hemorrhage, 

353 

Purulent  ophthalmia,  95 
Pustular  ophthalmia,  113 
Pyaemia,  disease  in,  379 
Pyramidal  cataract,  173 


35* 


414 


INDEX. 


QUININE  amblyopia,  381 

RECURRENT  vascular  ulcer,  115 
Eefraction  of  light,  13 

of  the  eye,  25 

determination  by  ophthalmo- 
scope, 73 
retinoscopv,  78 

errors  of,  287 
Refractive  index,  13 
Relapsing  fever,  diseases  from, 

378 

Relative  accommodation,  45 
Renal  retinitis,  207,  383 
Retina,  diseases  of,  203 

appearances  in  disease,  205 
in  health,  70,  203 

atrophy,  208 

bloodvessels  of,  203 

concussion,  164 

congestion  of,  205 

detachment,     162,    211,    255, 
382 

embolism  of,  213 

functional  diseases,  246 

glioma,  282 

hyperaesthesia,  244 

hemorrhage,  208,  379 

in  disease  of  choroid,  188 
disk,  211 

pigmentation,  208,  221 
Retinal  image,  size  in  hyperme- 
tropia,  300 

in  myopia,  289 
Retinitis,  206 

albuminuric,  214,  382 

apoplectic,  217 

hemorrhagic,  217 

pigmentosa,  220 

pernicious  anajmia,  383 

lead,  380 

leucocythsemic,  383 

malarial,  378 

renal  (see  Albuminuric). 

syphilitic,  213,  374 
Retrobulbar  neuritis,  231,  240 
Retinoscopy,  78 
Rheumatism,  disease  in,  384 
Rodent  ulcer,  86 
Rupture  of  choroid,  162,  195 

eyeball,  161 


SAEMISCH'S  operation,  123 
Sarcoma  of  choroid,  283 

ciliary  body,  283 

iris,  286 

sclerotic,  278 
Scalds  of  eye,  165 
Scarlet  fever,  diseases  from,  376 
Scleral  ring,  69 
Sclero-iritis,  147 
Sclero-keratitis,  147 
Sclerotic,  rupture  of,  161 
' '  Sclerotico  -  choroiditis      poste- 
rior," 199 
Sclerotitis,  145 
Sclerotomy,  268 

Scotoma  (a  defect  or  blind  patch 
in  field  of  vision,  caused  by 
localized  opacity  of  media, 
disease  of  fundus  or  optic 
nerve),  central,  241 

flittering,  387 
Scrofulous  sclerotitis,  147 
Scurvy,  retinal  hemorrhage,  379 
Secondary  cataract,  175,  187 

keratitis,  130 

glaucoma,  256,  273 

operations   for   cataract,   186, 
369 

squint,  32,  328 

Senile  changes  in  accommoda- 
tion, 316 

choroid,  199 

lens,  171 

failure  of  vision,  43 
Serous  iritis,  149,  154 
Seton  in  corneal  ulcer,  121 

syphilitic  keratitis,  129 
Shades,  403 
Sight  (see  Vision). 

after  cataract  operations,  186 

in  optic  atrophy,  234 

neuritis,  229 
Size,  apparent,  of  objects,  45 

of  retinal  image,  influence  of 

lenses  on,  26 

Smallpox,  eye  diseases  in,  376 
Snow-blindness,  247 
Soft  cataract,  186 
Solution  of  cataract,  182 
Sparkling  synchysis,  254 
Spasm  of  accommodation,  290 


INDEX. 


415 


Spectacles  in  hypermetropia,  304 
astigmatism,  315 
myopia,  295 
presbyopia,  318 
unequal  eyes,  316 

prismatic,  298 
Spectacle  lenses,  table  of,  29 
"Spongy  exudation"  in  iritis, 135 
"  Spring-catarrh,"  115 
Squint  (see  Strabismus). 
Staphyloma,  anterior,  148 

posterior,  199,  292 
Stillicidum  lacrymarum,  90 
Strabismus,  definition  and  varie- 
ties, 32,  320 

alternating,  303 

apparent,  33 

causes  of,  323 

concomitant,  303       \ 

convergent,  32,  302    ) 

divergent,  32,  290 

examination  for,  32 

in  hypermetropia,  302 
myopia,  290 

paralytic,  324 

periodic,  303 

primary,  33,  328 

secondary,  32, 328 
Stricture  of  nasal  duct,  90 
Strumous  eye  diseases,  130,  386 
Stye,  83,  84 

Suction  of  cataract,  183 
Suppression   of   retinal    image, 

238,  323 
Sycosis  tarsi,  81 
Symblepharon  (adhesion  between 

palpebral  and  ocular  conjunc- 
tiva), 165,  276 
Sympathetic  inflammation,  151 

irritation,  151,  153 

nerve,  paralysis,  394 

ophthalmitis,  151,  153 
Syndectomy,  108 
Synechia  (adhesion  of  the  iris), 
anterior    (iris    adherent    to 
cornea),  165,  272 

causing  glaucoma,  139 

posterior  J(iris  adherent  to  cap- 
sule of  lens),  137 
Syphilis,  acquired,  eye  diseases, 

373 


Syphilis,  brain  disease,  389 
choroiditis,  194,  197 
cyclitis,  151 

hereditary,  eye  diseases,  375 
iritis,  139 
keratitis,  125 
ocular  paralysis,  374 
optic  neuritis,  375 

atrophy,  375 
orbital  disease,  374 
retinitis,  213 
tarsitis,  276 
ulcers  of  eyelid,  87 

TAT'S  choroiditis,  200 

Teeth  in  lamellar  cataract,  393 

hereditary  syphilis,  395 
Tension  of  eye,  examination,  30 

diminished,  151 

in  glaucoma,  256,  258 

iritis,  136 

paralysis  of  fifth,  267 
Test-types,  43 
Tinea  tarsi,  81 
Tobacco  amblyopia,  241,  381 
Toxic  amaurosis,  376,  380 
Trachoma     (granular    ophthal- 
mia), 103 

Trachomatous  pannus,  107 
i  Traumatic  astigmatism,  164 

cataract,  167,  180 

cycloplegia,  163 

irido-cyclitis,  140,  151,  168 

iridoplegia,  163 

iritis,  140,  143,  164, 185 

myopia,  164 

panophthalmitis,  141,  151 

ptosis,  159 
Tremulous  iris,  162 
Trichiasis  (irregular  growth  of 

eyelashes,  some  of  them  rubbing 

against  the  cornea),  108 
Tubercle  of  choroid,  194,  286 
Tuberculosis,  diseases  in,  384 
:  Tumors,  275 

intraocular,  282 

of  eyelids,  275 

front  of  eyeball,  275 
orbit,  278 

fluctuating  and  cystic,  280 

pulsating,  280 


416 


INDEX. 


Typhus,  diseases  from,  376 

ULCERS  of  cornea,  112 

eyelids,  86 
Undiscovered   blindness   of  one 

eye,  240 
Unequal  refraction   in  the   two 

eyes,  316 
Ursemic  amaurosis,  376 

Vence  vorticosce,  189 
Vision  (see  Sight). 

acuteness  of,  testing,  43 
field  of,  40 

optical  conditions  of  clear,  27 
Visual  angle,  26 
axis,  27 

field  for  colors,  250 
in  glaucoma,  258 
optic  atrophy,  235 
Vitreous,  cholesterine,  253 
disease  of,  149,  251 
in  glaucoma,  255 


Vitreous,  diseases  of,  in  choroi- 

ditis,  254 
myopia,  254,  293 
hemorrhage,  traumatic,  254 

spontaneous,  254 
humor,  examination,  73 

WATERY  eye,  90 
Wart,  conjunctival,  275 

marginal,  of  eyelid,  85 
Waxy  disk,  221 
Whooping-cough,  diseases  from, 

378 

Woolly  disk,  229 
Wounds  of  eyeball,  166 

eyelids,  160 

orbit,  160 

XANTHELASMA  palpebrarum,  86 
YELLOW  spot,  71,  204 
ZONTJLAR  cataract,  173,  178,  186 


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with  85  woodcuts.     Cloth,  $2  63.     (Lately  issued.) 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND 
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A  MANUAL  OF  AUSCULTATION  AND  PERCUSSION  ;  of  the 

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racic Aneurism.  Third  edition,  revised  and  enlarged.  In  one 
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A  PRACTICALTREATISEONTHE  DIAGNOSIS  ANDTREAT- 

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A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
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edition.  In  one  octavo  volume  of  591  pages.  Cloth,  $4  50. 

CLINICAL  MEDICINE.     A  SYSTEMATIC    TREATISE  ON 


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ON  PHTHISIS:  ITS  MORBID  ANATOMY, ETIOLOGY,  ETC., 

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POSTER  (MICHAEL).    A  TEXT-BOOK  OF  PHYSIOLOGY.    Second 

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pOTHERGILL'S  PRACTITIONER'S  HANDBOOK  OF  TREATMENT. 

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pOWNES  (GEORGE).  A  MANUAL  OF  ELEMENTARYCHEMISTRY. 

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FOX  (TILBURY).    EPITOME  OF  SKIN  DISEASES,  with  Formulae 
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PULLER  (HENRY).    ON  DISEASES  OF  THE  LUNGS  AND  AIR 
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GALLOWAY  (ROBERT).     A  MANUAL  OF  QUALITATIVE  ANAL- 
YSIS.    From  the  sixth  London  edition.     (Preparing.) 
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GLUGE  (GOTTLIEB).   ATLAS  OF  PATHOLOGICAL  HISTOLOGY. 
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which  is  added  Holden's  "Landmarks,  Medical  and  Surgical."7  with 
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GREEN  ,T.  HEHRY).  AN  INTRODUCTION  TO  PATHOLOGY  A5D 
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SAMUEL   W.)      A    PRACTICAL   TREATISE    ON    IMPO- 
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(A.)   A  TBJBATISB  OH  UTERINE  TUMORS.   Revised  by 


G 


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HALL   XRS.M.'    LIVES  OF  THE  QUEENS  UF  ENGLAND  BEFORE 
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A  CONSPECTUS  OF  THE  MEDICAL  SCIENCES.  Comprising 

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HEATH  (CHRISTOPHER).    PRACTICAL  ANATOMY  :   A  MANUAL 
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TTERMANN    L  )     EXPERIMENTAL  PHARMACOLOGY.     A  Hand- 
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SILLIER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES.   2d  ed. 
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HOBLYN  >R"ICHARD  D.I  A  DICTIONARY  OF  THE  TERMS  USED 
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H OLDEN  (LUTHEn).  LANDMARKS.  MEDICAL  AND  SURGICAL. 
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HUDSON  (A.)  LfalCTURES  ON  THE  STUDY  OF  FEVER.  In 
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TONES  (C.  HANDFIELD).    CLINICAL  OBSERVATIONS  ON  FUNC- 
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KEATING  (JOHN  M.)     THE    CARE  OF  INFANTS.     In  one  small 
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LA  ROCHE  (R.)    YELLOW  FEVER.    In  two  8vo.  vols.  of  1468  pages. 
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PNEUMONIA.    In  one  8vo.  vol.  of  490  pages.     Cloth,  $3. 

T  ATTRENCE  (J.  Z.)  AND  MOON  (ROBERT  C.)     A  HANDY-BOOK 
•Ll     OF  OPHTHALMIC  SURGERY.     Second  edition,  revised  by  Mr. 

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T  AWSON  (GEORGE) .  INJURIES  OF  THE  EYE,  ORBIT  AND  EYE- 
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volume  of  404  pages,  with  92   illustrations.     Cloth,  $3  50. 
T  EA  ( HENRY  C.)  SUPERSTITION  AND  FORCE  ;  ESSAYS  ON  THE 
JJ     WAGER  OF  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL 

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STUDIES  IN  CHURCH  HISTORY.     The  Rise  of  the  Temporal 

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AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY 


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T  EE  (HENRY)  ON  SYPHILIS.  In  one  8vo.  vol.  pp.  246.  Cloth,  $2  25. 

T  EHMANN  (C.  G.)     A  MANUAL  OF   CHEMICAL  PHYSIOLOGY. 
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T  EISHMAN  (WILLIAM).     A  SYSTEM  OF  MIDWIFERY.     Includ- 
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American,  from  the  third  English  edition.     With  additions,  by 

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T  UDLOW  (J.  L.)    A   MANUAL  OF  EXAMINATIONS  UPON  ANA- 
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OBSTETRICS,  MATERIA  MEDICA,  CHEMISTRY,  PHARMACY 

AND  THERAPEUTICS.    To  which  is  added  a  Medical  Formulary. 

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T  YNCH  (W.  F.)     A  NARRATIVE  OF  THE  UNITED  STATES  EX- 
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T  YONS  (ROBERT  D.)     A  TREATISE  ON  FEVER.     In  one  octavo 
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MACFARLANE'S  TURKEY  AND  ITS  DESTINY.  In  2  vols.  royal 
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MEIGS  (CHAS.  D.)    ON  THE  NATURE,  SIGNS  AND  TREATMENT 
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TV/TILLER  (JAMES).  PRINCIPLES  OF  SURGERY.  Fourth  American, 
-*•*-*•  from  the  third  Edinburgh  edition.      In  one  large  octavo  volume  of 
688  pages,  with  240  illustrations.     Cloth,  $3  75. 

THE  PRACTICE  OF  SURGERY.     Fourth  American,  from  the 

last  Edinburgh  edition.  In  one  large  octavo  volume  of  682  pages, 
with  364  illustrations.  Cloth,  S3  75. 

MITCHELL   (S.  WEIB).     LECTURES    ON  NERVOUS   DISEASES, 
ESPECIALLY  IN  WOMEN.     Second  edition.     (Preparing.) 
MONTGOMERY  (W.  F.)      AN  EXPOSITION  OF  THE  SIGNS  AND 
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MORRIS  (MALCOLM).  SKIN  DISEASES:  Including  their  Defini- 
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MULLER  (J.)  PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY. 
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NEILL  (JOHN)  AND  SMITH  (FRANCIS  G.)  A  COMPENDIUM  OF 
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PAVY  (F.  W.)    A  TREATISE  ON  THE  FUNCTION  OF  DIGESTION, 
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pIRRIE  (WILLIAM).  THE  PRINCIPLES  AND  PRACTICE  OF  SUR- 
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by  the  Author.  Edited,  with  additions,  by  R.  P.  Harris,  M.D. 
In  one  handsome  octavo  volume  of  659  pages,  with  183  woodcuts, 
and  two  plates.  Cloth,  $4  :  leather,  $5  ;  very  handsome  half  Rus- 
sia, raised  bands,  $5  50  ( Just  issue/I.) 

THE  SYSTEMATIC  TREATMENT  OF  NERVE    PROSTRA- 

T10N  AND  HYSTERIA.    In  one  handsome  12mo.  vol.    (In  press  ) 

pOLITZER  (ADAM).    A  TEXT-BOOK  OF  THE  EAR  AND  ITS  DIS- 

•*•      EASES.     Translated  at  the  Author's  request  by  James  Patterson 

Cassells,  M.D,  F.F.P.S.     In  one  handsome  octavo  volume  of  800 

pages,  with  257  original  illustrations.     Cloth,  $5  50.     (Just  ready.) 

PULSZKY'S  MEMOIRS  OF  AN  HUNGARIAN  LADY.    In  one  royal 

•t      12mo.vol.     Cloth,  $1. 

pAMSBOTHAM   (FRANCIS    H.)     THE  PRINCIPLES  AND  PRAC- 
-tu    TICE  OF  OBSTETRIC  MEDICINE  AND  SURGERY.    Inoneim 
perial  octavo  volume  of  640  pages,  with  64  plates,  besides  numerous 
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10          HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

T)EMSEN(IRA).   THE  PRINCIPLES  OF  CHEMISTRY.    Second  edi- 
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•DEYNOLDS  (J.  RUSSELL)      A  SYSTEM  OF  MEDICINE, with  Notes 
•*•*•     and  Additions,  by  HENRY  HARTSHOUNE,  M.D.    In  three  large  8vo. 
vols.,  containing  3056  closely  printed  double-columned  pages,  with 
317  illus.     Per  vol.,  cloth,   $5;  leather,  $6;    very  handsome  half 
Russia,  $650.      (Now  ready.)     For  sale  by  subscription  only. 
TDICHARDSON  (BENJAMIN  W.)    PREVENTIVE  MEDICINE.    In 
•I-**     one  octavo  volume  of  about  500  pages.     (Preparing.) 
•ROBERTS  (JOHN  B.)     THE    PRINCIPLES    AND   PRACTICE    OF 
•L"    SURGERY.     In  one  octavo  volume  of  about  500  pages,  fully  illus- 
trated.     (Preparing.) 

•ROBERTS  (WILLIAM).   A  PRACTICAL  TREATISE  ON  URINARY 

•"    AND  RENAL  DISEASES.     Fourth  American,  from  the  fourth 

London  edition.    With  numerous  illustrations  and  a  colored  plate. 

In  one  very  handsome  8vo.  vol.  of  over  600  pages.     (Preparing.) 

OARGENT  (F.  W.)  ON  BANDAGING  AND  OTHER  OPERATIONS 

&     OF  MINOR  SURGERY.     New  edition,  with  an  additional  chapter 

on  Military  Surgery.    In  one  handsome  royal  12mo.  volume  of  383 

pages,  with  187  woodcuts.     Cloth,  SI  75. 

qCHAFER  (EDWARD  ALBERT) .  A  COURSE  OF  PRACTICAL  HIS- 

•^      TOLOGY  :  A  Manual  of  the  Microscope  for  Medical  Students.    In 

one  handsome  octavo  volume,  with  many  illustrations.    Cloth,  $2. 

OCHMITZ  AND  ZUMPT'S  CLASSICAL  SERIES.     In  royal  ISmo. 

K>  ADVANCED    LATIN    EXERCISES,    AVITH    SELECTIONS    FOR 

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OCHOEDLER  (FREDERICK)  AND  MEDLOCK( HENRY).  WONDERS 
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Physics,  Astronomy,  Chemistry,  Mineralogy,  Geology,  Botany,  Zool- 
ogy and  Physiology.     Translated  from  the  German  by  H.  Medlock. 
In  one  8vo.  vol.,  with  679  illustrations.    Cloth,  £3. 

SEILER  (CARL).  A  HANDBOOK  OF  DIAGNOSIS  AND  TREAT- 
MENT OF  DISEASES  OF  THE  THROAT  AND  NASAL  CAV- 
ITIES. Second  edition.  (In  press.) 

QHARPEY    (WILLIAM)    AND  QUAIN  (JONES    AND  RICHARD). 
*J     HUMAN  ANATOMY.     With  notes  and  additions  by  Jos.  Leidy, 
M.  D.,  Prof,  of  Anatomy  in  the  University  of  Pennsylvania.    In  two 
large  8vo.  vols.  of  about  1300  pages,  with  51 1  illustrations. 

S KEY  (FREDERIC  C.)     OPERATIVE  SURGERY.    In  one  8vo.  vol. 
of  over  650  pages,  with  81  woodcuts.     Cloth,  $3  25. 
SLADE(D.D-)    DIPHTHERIA;  ITS  NATURE  AND  TREATMENT. 
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QMALL  BOOKS  ON  GREAT  SUBJECTS.     In  3  vols.    Cloth,  $1  50. 
io 

SMITH  (EDWARD).  CONSUMPTION;  ITS  EARLY  AND  REME- 
DIABLE STAGES.  In  one  8vo.  vol.  of  253  pp.  Cloth,  $2  25. 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS.          11 


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^  Second  American  edition,  enlarged.  In  one  8vo.  vol.  Cloth,  $2  50. 
QIMITH  (HENRY  H.)  AND  HORNER  (WILLIAM  E.)  ANATOMICAL 
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large  imperial  8  vo.  vol.,  with  about  650  beautiful  figures.  Clo.,  $4  50. 

SMITH  (J.LEWIS).  A  TREATISE  ON  THE  DISEASES  OF  IN- 
FANCY AND  CHILDHOOD.  Fifth  edition,  revised  and  enlarged. 
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$4  50  ;  leather,  $5  50  ;  very  handsome  half  Russia,  raised  bands, 
$6.  (Just  ready.) 

OTILLE  (ALFRED).    THERAPEUTICS  AND  MATERIA  MEDIC  A. 

*^     Fourth  revised  edition.     In  two  handsome  octavo  volumes  of  1936 

pages.    Cloth, $10;  leather, $12;  very  handsome  half  Russia,  $13. 

STILLE  (ALFRED)  AND  MAISCH  (JOHN  M.)  THE  NATIONAL 
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Use  of  Physicians  and  Pharmaceutists.  Second  edition,  revised 
and  enlarged.  In  one  handsome  octavo  volume  of  1692  pages, 
with  239  illustrations.  Cloth,  $6  75;  leather,  $7  50;  very  hand- 
some half  Russia,  raised  bands,  $8  25.  (Just  issued.) 
STIMSON  (LEWIS  A.)  A  PRACTICAL  TREATISE  ON  FRAG- 
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OTOKES(W-)    LECTURES  ON  FEVER.    In  one  Svo.  vol.    Cloth,  $2. 

STRICKLAND  (AGNES).    LIVES  OF  THE  QUEENS  OF  HENRY 

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$1  40;  black  cloth,  $1  30. 

QTURGES    (OCTAVIUS).     AN   INTRODUCTION    TO  THE  STUDY 

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rpANNER  (THOMAS  HAWKES) .   A  MANUAL  OF  CLINICAL  MEDI- 

-L  CINE  AND  PHYSICAL  DIAGNOSIS.  Third  American  from  the 
second  revised  English  edition.  Edited  by  Tilbury  Fox,  M.  D.  In 
one  handsome  12mo.  volume  of  362  pp.,  with  illus.  Cloth,  $1  50. 

ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.    From 

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four  colored  plates  and  numerous  woodcuts.  Cloth,  $4  25. 

ipAYLOR    (ALFRED   S.)     MEDICAL  JURISPRUDENCE.      Eighth 

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Author.  Edited  by  John  J.  Reese,  M.D.  In  one  large  octave 
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ON  POISONS  IN  RELATION  TO  MEDICINE  AND  MEDICAL 

JURISPRUDENCE.  Third  American  from  the  third  London  edi- 
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Cloth,  $5  50;  leather,  $6  50.  (Just  issued.) 

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PRUDENCE. Third  edition.  In  two  handsome  vols.  (In  Press.) 

rpHOMAS  (T.  GAILLARD) .    A  PRACTICAL  TREATISE  ON  THE 

-L     DISEASES  OF   WOMEN.    Fifth  edition,  thoroughly  revised  and 

rewritten.    In  one  large  and  handsome  octavo  volume  of  810  pages, 

with  266  illustrations.    Cloth,  $5  ;  leather,  $6  ;  very  handsome  half 

Russia,  $6  50.     (Just  issued.) 


12          HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

THOMPSON  (SIR  HENRY) .   CLINICAL  LECTURES  ON  DISEASES 
-1-     OF  THE  URINARY  ORGANS.     Second  and  revised  edition.    In 
one  octavo  volume  of  203  pages,  with  illustrations.    Cloth,  $2  25. 


: THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  URETHRA  AND  URINARY  FISTULA.  From  the  third 
English  edition.  In  one  octavo  volume  of  359  pages,  with  illus- 
trations. Cloth,  $3  50. 

TIDY  (CHARLES  MEYMOTT).  LEGAL  MEDICINE.  Volume  I. 
In  one  handsome  imperial  octavo  volume  of  664  pages,  with  2  col- 
ored plates.  Cloth,  $6  ;  leather,  $7. 

rpDDD  (ROBERT  BENTLEY) .  CLINICAL  LECTURES  ON  CERTAIN 
-1-     ACUTE  DISEASES.    In  oneSvo.  vol.  of  320  pp.,  cloth,  $2  50. 

rpUKE  (DANIEL  HACK)     THE  INFLUENCE  OF  THE  MIND  UPON 
•*"      THE  BODY.   Newedition.    In  one  handsome  8  vo.  vol.  (Preparing.) 

WALSHE  (W.  H.)  PRACTICAL  TREATISE  ON  THE  DISEASES 
OF  THE  HEART  AND  GREAT  VESSELS.  3d  American  from  the 
3d  revised  London  edition.  In  one  8vo.  vol.  of420  pages.  Cloth,  $3. 

WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  PHYSIC.  A  new  American  from  the  fifth  and  en- 
larged English  edition,  with  additions  by  H.  Hartshorne,  M.D.  In 
two  large  Svo.vols.  of  1840  pp.,  with  190  cuts.  Clo.,  $9  ;  lea. ,$11. 

WELLS  (J.  SOELBERG)  A  TREATISE  ON  THE  DISEASES  OF 
THE  EYE.  Third  edition,  enlarged  and  thoroughly  revised  by 
Chas.  S.  Bull,  A.M.,  M.D.  In  one  large  and  handsome  octavo  vol. 
of  883  pages,  with  6  colored  plates  and  254  woodcuts,  also  selec- 
tions from  the  test-types  of  Jaeger  and  Snellen.  Cloth,  $5  ;  leather, 
$6;  very  handsome  half  Russia,  $6  50.  (Just  issue/I.) 

WEST  (CHARLES).     LECTURES  ON  THE  DISEASES  PECULIAR 
TO  WOMEN.    Third  American  from  the  third  English  edition.    In 
one  octavo  volume  of  543  pages.     Cloth,  $3  75  ;  leather,  $4  75. 
LECTURES  ON  THE  DISEASES  OF  INFANCY  AND  CHILD- 
HOOD.   Fifth  American  from  the  sixth  revised  English  edition.    In 
one  large  8vo.  vol.  of  686  pages.     Cloth,  $4  50  ;  leather,  $5  50. 
ON  SOME  DISORDERS   OF    THE    NERVOUS   SYSTEM    IN 


CHILDHOOD.  From  the  London  edition.  In  one  small  12mo. 
volume  of  127  pages.  Cloth,  $1. 

WILLIAMS  (CHARLES  J.  B.  and  C.  T.)  PULMONARY  CONSUMP- 
TION :  ITS  NATURE,  VARIETIES  AND  TREATMENT.  ID 
one  octavo  volume  of  303  pages.  Cloth,  $2  50. 

WILSON  (ERASMUS).  A  SYSTEM  OF  HUMAN  ANATOMY.  A 
new  and  revised  American  from  the  last  English  edition.  Illustrated 
with  397  engravings  on  wood.  In  one  handsome  octavo  volume 
of  616  pages.  Cloth,  $4  ;  leather,  $5. 

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE.     In 

one  handsome  royal  12mo.  vol.     Cloth,  $3  50. 

WINCKEL  ON  PATHOLOGY  AND  TREATMENT  OF  CHILDBED. 
With  additions  by  the  Author.  Translated  by  James  R.  Chad  wick. 
In  one  handsome  octavo  volume  of  484  pages.  Cloth,  $4. 

WOHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY.  Translated 
from  the  8th  German  edition,  by  Ira  Remsen,  M.D.  In  one  12mo. 
volume  of  550  pages.  Cloth,  $3  00. 

WOODBDRY  (FRANK).  A  HANDBOOK  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  MEDICINE.  In  one  royal  12mo.  volume. 
(Preparing.) 


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